Wednesday, June 10, 2015

Cognitive Therapy, Cognitive Dissonance

One of the most frequent recommendations I see resulting from our peer-to-peer discussions on chronic pain claims is Cognitive Behavioral Therapy (CBT).  CBT is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving.  Its goal is to change patterns of thinking or behavior that are behind people's challenges and, thus, change the way they feel about and deal with those challenges.

Despite the growing body of evidence regarding the effectiveness of Cognitive Behavioral Therapy, it still seems to cause a great deal of cognitive dissonance in our industry.  We want to mitigate chronic pain symptoms for injured workers so they can take fewer medications, have a higher quality of life, and perhaps even return to work.  But we're resistant to the idea that 6-12 CBT sessions can actually help with those goals, despite what the evidence suggests.

The essential concept here is that low-cost, short-term clinical strategies that focus on how we feel, react, and deal with life experiences, including symptoms of pain, can be more effective than long-term use of medications.

An article in the New York Times this week lends more evidence to this notion.  While not focused on chronic pain, the article does highlight one of the most significant side effects of chronic pain (and the opioids too often used to manage it): insomnia.  Look at the medications you're paying for on a typical legacy chronic pain case and you're likely to see Lunesta, Ambien (zolpidem), Restoril, etc.

Turns out CBT by itself is more effective than both the medications as well as the medications plus CBT.  Across 20 clinical trials including more than 1,000 patients, CBT yielded more sleep and higher quality sleep than the medications delivered.

Here's the bottom line: All of us, at one time or another and with varying degrees of frequency, need coping mechanisms.  Life is hard.  Sometimes we hurt.  Sometimes, we hurt all the time.  But medication therapy isn't the best option for long-term pain or insomnia or lots of other chronic conditions that fundamentally emanate from the human mind and all of its experiences and perceptions.  CBT sounds simple.  It's not.  CBT is hard work.  We're trying to rewire our brains so that we experience life in a healthier way.  But it's hard work worth doing, particularly given the alternatives.  

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