Assessment and Treatment of Chronic Pain in Military Populations is a training aimed at mental health practitioners who have a basic working knowledge of cognitive behavioral therapy. Aims of the training are as follows: 1) to educate practitioners on how psychological and social factors can influence chronic pain development, presentation, and outcomes, 2) to discuss the scope of chronic pain in the military and factors unique to military patients with pain, 3) to teach practitioners to conduct a thorough psychological assessment of chronic pain patients, and 4) to demonstrate how to apply cognitive-behavioral therapy principles to the treatment of chronic pain and associated distress.
Participants are taught to assess biological, psychological, and social aspects of chronic pain. This is done through detailed discussion of theoretical models underlying chronic pain, review of literature surrounding comorbid psychological conditions in civilian and military populations, and discussion of factors influencing the outcome of pain. Participants watch an instructive video about the role of psychological variables in pain. They also participate in small group discussions about sample chronic pain patients in which they delineate the psychosocial variables affecting the patients’ pain. Further, they watch a video of a former military member discussing her chronic pain and how it impacted her psychological health.
Participants learn the major domains to assess in an intake interview of a chronic pain patient. They are given a structured pain assessment interview, and they practice conducting this interview in role plays. They are also given the Defense and Veterans Pain Rating Scale and Supplemental Questions. Several additional questionnaires are recommended, with most attention paid to the McGill Pain Scale and the West Haven Yale Multidimensional Pain Inventory. Information for how to obtain these free measures is included in the training. The training also briefly discusses measures for specific domains such as fear of movement and somatic focus.
The cognitive-behavioral treatment protocol is adapted from The Pain Survival Guide by Dennis Turk and Frits Winter. All participants receive a copy of this book. Participants are taught that providing clear psychoeducation regarding pain is critical to gaining patient acceptance of and adherence to the therapy. Therefore, participants watch a recorded session of psychoeducation with a simulated patient and also practice this skill in role plays. The benefits of relaxation in chronic pain are discussed, and participants participate in a guided demonstration of four relaxation techniques: diaphragmatic breathing, progressive muscle relaxation, autogenic relaxation, and visualization. They are directed toward internet resources (websites and apps) that include recorded relaxation scripts.
Participants learn to help patients pace their activities, improve their sleep, and modify pleasurable activities to fit their physical limitations or select new activities that they might enjoy. They receive patient handouts for all of these domains. Participants also learn to apply cognitive therapy principles to patients’ thoughts about their pain and associated limitations. The workshop discusses cognitive distortions common in pain patients, ways of helping patients learn to find evidence for and against negative pain-related cognitions, and how to aid patients in selecting positive coping thoughts. Participants role play helping patients challenge negative pain-related thoughts using worksheets provided by the workshop. The workshop further discusses ways that chronic pain can impact family relationships. Participants learn ways of intervening to promote positive communication between the pain patient and his/her family members regarding the pain. Finally, participants are instructed in how to help patients anticipate and cope with setbacks. Other interventions, to be used as needed, include instructing in anger management, challenging fear/avoidance beliefs, and assertiveness training.
There is not a set length of sessions for the protocol, which should be adapted to fit the needs of the patient. It is suggested that 5 sessions be used as a minimum with patients who have few psychological issues apart from their pain, with further additional sessions added as needed. For example, a patient with pain and depressed mood would benefit from additional, more in-depth work in behavioral activation and cognitive techniques.
In addition to learning the skills/techniques listed above, the workshop also discusses the common issue of pain patients’ resistance to psychological service for pain management. Participants learn ways of empathizing with and defusing resistance, as well as techniques for motivating patients for change. Issues related to pain management in nontraditional settings, such as on deployments or in medical inpatient facilities are also discussed.
By the end of the workshop, participants will be able to:
1. Describe current theoretical models of chronic pain
2. Identify common co-morbid mental health conditions in pain patients
3. Discuss specific issues relevant to military populations and chronic pain
4. Explain how psychosocial factors can influence the outcome of chronic pain
5. Perform basic psychological assessments of chronic pain patients
6. Provide cognitive-behavioral therapy for chronic pain