How Is this applied to Chronic Pain Clients?

As noted by multiple researchers changing the order of DBT modules can make DBT more effective for chronic pain clients (Cavicchioli et al, 2021; Norman-Nott et al., 2021, Linehan, 2021, Linton, 2010; Reutter, 2021).

Most recommend beginning with emotion regulation and distress tolerance first as they are key to correcting skills deficits and treating disorders in this population.

Due to its flexible style of therapy it can be quite an affordable option for clients. This is important as many may be on disability due to their illness. Yet they can do DBT therapy through groups online, and virtual therapy, making it an affordable quality service for this population.

Where do you begin and Why?

DBT modules can help chronic conditions specifically is through the way they use dialectical language and motivation between acceptance and change. As Dr. Barret describes it, "two modules focus on acceptance which is validating of chronic pain. While the other two focus on change and the problem solving areas that can help with chronic pain" (Barret, 2013).

And as Chronic conditions are often comorbid with mental health conditions for example those with fibromyalgia often also have depression (Mate, 2021). As Dr. Mate notes in his book when the body says no. And Dr. Barret (2013) noted further that, "physical and emotional pain are often interrelated: Living with physical pain can be emotional taxing! Plus, pain symptoms are often exacerbated when we feel emotionally vulnerable". And as such often these clients have skills deficits in emotion regulation and distress tolerance areas as found by multiple researchers. Therefore when beginning DBT with clients that have chronic health conditions it is best to be mindful of where they are at.

This brings us to the question where do you begin and why? It is recommended that distress tolerance be the first module as pain can increase and flare up conditions if clients’ emotions are too intense. Cavicchioli and colleagues recommend the following order, of beginning with emotion regulation and distress tolerance and then following that with the mindfulness and interpersonal skills modules in later stages of therapy.

Skills that have a Big impact on Chronic Pain

Some skills will have more of an impact with chronic conditions and this can be due to the invalidation clients face when they have an invisible illness. The DBT skills that work on self-care and in the distress tolerance module can help with the invalidation clients face by also teaching them the ability to self-validate, and radical acceptance of their situations. As Marsha Linehan has found, often clients fight their reality and this wastes energy and causes distress. Through radical acceptance its teaching the client to give up the fight with reality. It’s not about being passive, condoning the negative event, it’s simply coming into contact with it and acknowledging it. Then to also validate them and encourage change.

This can be through interpersonal effectiveness skills as they can also help clients to understand that everyone is wired differently and they may need to learn ways to adapt their style of communicating in order to be more effective. These are particularly helpful when they are in pain and it may be difficult to think through how to best word conversations when they are also managing physical symptoms. For example, the DEARMAN skill can be used and walks them through how to effectively communicate their wishes.

Sometimes clients have to choose their health over disappointing others, and as a therapist it needs to be celebrated as a courageous choice. In session a skill that can help them do this is through the DEAR part of DEAR MAN as this part is the what part as in what the client does specifically. We develop a script or role play how that might go. D for Describing the situation, E for Expressing their feelings about the situation, A for asserting what they need or saying no to an event and R for reinforcing or rather explaining the positive reward that will be gained for both parties.

Then the MAN part of DEAR MAN is the how they do the skills. Mindfully, Appearing confident, and being willing to negotiate with the others.

Case Study Example

I wanted to share a case study from Dr. Linton as it described the effectiveness of DBT in the chronic pain population and can display further ways of implementation.

Positive results:

A 52-year-old adult suffering musculoskeletal pain, work disability, depression, and mood swings was offered therapy. She had not worked at her occupation for 10 years. An intervention was developed based on dialectical behavior therapy that included goal setting, validation, behavioral experiments and interoceptive exposure. Goals were developed with the client, based on her own values, and these were to: increase participation in previously enjoyable activities, not only reduce but also accept that some pain may remain, and, express and regulate emotions.

Validation (understanding the patient’s situation) and psychoeducation were used to analyze the problem with the patient in focus. Function was approached by monitoring activities and conducting dialectical behavioral experiments where the patient systematically approached activities she no longer participated in (exposure). Emotional regulation followed a training program developed in dialectical behavior therapy designed to have people experience, express, and manage a variety of positive and negative emotions. In order to address the patient’s complaint that she avoided her own feelings as well as the pain, interoceptive exposure was introduced. After establishing calm breathing, the client was asked to focus attention on the negative feelings or pain as a way of de-conditioning the psychological responses to them. Therapy was conducted during 16 sessions over a six-month period.

Outcome:

The Pain intensity ratings dropped from 4.3 during the baseline to almost 0 at the end of treatment. Function increased as the patient participated in goal activities. Depression scores were decreased from 26 (Beck’s Depression Inventory) at pre treatment to 5 at follow-up, which falls within the normal range.

Now it’s time to choose your adventure if you want to learn more about other chronic illness counselling services, look into our Chronic Disease Self-Management Program and Meet out Chronic illness Therapist? Hit a button below to learn more!