Adult Treatment Planner

Objectives and Interventions

• Describe the nature of, history of, impact of, and understood causes of chronic pain.
  • Assess the history and current status of the client's chronic pain.
  • Explore the changes in the client's mood, attitude, social, vocational, and familial/marital roles that have occurred as a result of the pain.
• Complete a thorough medical examination to rule out any alternative causes for the pain and reveal any new treatment possibilities.
  • Refer the client to a physician or clinic to undergo a thorough examination to rule out any undiagnosed condition and to receive recommendations on any further treatment options.
• Follow through on a referral to a pain management or rehabilitation program.
  • Give the client information on the options of pain management specialists or rehabilitation programs that are available and help him/her make a decision on which would be the best for him/her.
  • Make a referral to a pain management specialist or clinic of the client's choice and have him/her sign appropriate releases for the therapist to have updates on progress from the program and to coordinate services.
  • Elicit from the client a verbal commitment to cooperate with pain management specialists, headache clinic, or rehabilitation program.
• Complete a thorough medication review by a physician who is a specialist in dealing with chronic pain or headache conditions.
  • Ask the client to complete a medication review with a specialist in chronic pain or headaches; confer with the physician afterward about his/her recommendations and process them with the client.
• Participate in a cognitive behavioral group therapy for pain management.
  • Form a small, closed enrollment group (4-8 clients) for pain management (see Group Therapy for Patients with Chronic Pain by Keefe, Beaupre, Gil, Rumble, and Aspnes).
• Verbalize an understanding of pain.
  • Teach the client key concepts of rehabilitation versus biological healing, conservative versus aggressive medical interventions, acute versus chronic pain, benign versus nonbenign pain, cure versus management, appropriate use of medication, role of selfregulation techniques, and so on.
• Verbalize an understanding of the rationale for treatment.
  • Teach the client a rationale for treatment that helps him/her understand that thoughts, feelings, and behavior can affect pain and emphasizes the role that the client can play in managing his/her own pain.
  • Assign the client to read sections from books or treatment manuals that describe pain conditions and their cognitive behavioral treatment (e.g., The Chronic Pain Control Workbook by Catalano and Hardin).
• Identify and monitor specific pain triggers.
  • Teach the client self-monitoring of his/her symptoms; ask the client to keep a pain journal that records time of day, where and what he/she was doing, the severity, and what was done to alleviate the pain (or assign "Pain and Stress Journal" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); process the journal with the client to increase insight into nature of the pain, cognitive, affective, and behavioral triggers, and the positive or negative effect of the interventions they are currently using.
• Learn and implement somatic skills such as relaxation and/or biofeedback to reduce pain level.
  • Teach the client relaxation skills (e.g., progressive muscle, guided imagery, slow diaphragmatic breathing) and how to discriminate better between relaxation and tension; teach the client how to apply these skills to his/her daily life (see Progressive Relaxation Training by Bernstein and Borkovec).
  • Refer the client for or conduct biofeedback training (e.g., EMG for muscle tension-related pain, thermal for migraine pain). Assign practice of the skill at home.
  • Identify areas in the client's life that he/she can implement skills learned through relaxation or biofeedback.
  • Assign a homework exercise in which the client implements somatic pain management skills and records the result; review and process during the treatment session.
  • Assign the client to read about progressive muscle relaxation and other calming strategies in relevant books or treatment manuals (e.g., Progressive Relaxation Training by Bernstein and Borkovec).
• Incorporate physical therapy into daily routine.
  • Refer the client for physical therapy if pain is heterogeneous.
• Learn mental coping skills and implement with somatic skills for managing acute pain.
  • Teach client distraction techniques (e.g., pleasant imagery, counting techniques, alternative focal point) and how to use them with relaxation skills for the management of acute episodes of pain.
• Increase the level and range of activity by identifying and engaging in pleasurable activities.
  • Ask the client to create a list of activities that are pleasurable to him/her; process the list, developing a plan of increasing the frequency of engaging in the selected pleasurable activities.
• Identify negative pain-related thoughts and replace them with more positive coping-related thoughts.
  • Explore the client's schema and self-talk that mediate his/her pain response, challenging the biases; assist him/her in generating thoughts that correct for the biases, facilitate coping, and build confidence in managing pain.
  • Assign the client a homework exercise in which he/she identifies negative pain-related self-talk and positive alternatives (or assign "Journal and Replace Self-Defeating Thoughts" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); review and reinforce success, providing corrective feedback toward improvement.
  • Assign the client to read about cognitive restructuring in relevant books or treatment manuals (e.g., The Chronic Pain Control Workbook by Catalano and Hardin).
• Integrate and implement new mental, somatic, and behavioral ways of managing pain.
  • Assist client in integrating learned pain management skills (e.g., relaxation, distraction, activity scheduling) into a progressively wider range of daily activities; record and review.
• Problem-solve obstacles to implementation of new ways to manage pain.
  • Teach the client problem-solving skills to apply to removal of obstacles to implementing new skills.
• Implement relapse prevention strategies for managing future challenges.
  • Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of pain or old habits (e.g., a "bad day") and relapse with the persistent return of pain and previous cognitive and behavioral habits that exacerbate pain.
  • Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur, using the strategies learned during therapy.
  • Follow up with the client periodically to problem-solve difficulties and reinforce successes.
• Incorporate physical exercise into daily routine.
  • Assist the client in recognizing the benefits of regular exercise, encouraging him/her to implement exercise in daily life and monitor results; offer ongoing encouragement to stay with the regimen.
  • Refer the client to an athletic club to develop an individually tailored exercise or physical therapy program that is approved by his/her personal physician.
  • Refer the client to a beginners' yoga class.
• Make changes in diet that will promote health and fitness.
  • Refer the client to a dietician for consultation around eating and nutritional patterns; process the results of the consultation, identifying changes he/she can make and how he/she might start implementing these changes.
• Investigate the use of alternative therapies to pain management.
  • Explore the client's openness to alternative therapies for pain management (e.g., acupuncture, hypnosis, therapeutic massage); refer for the services, if indicated.
• Learn and implement stress management techniques.
  • Teach the client stress management techniques (e.g., deep muscle relaxation, distraction, cognitive restructuring, increased pleasurable activities) to manage stressors that may be exacerbating pain or his/her vulnerability to it.
  • Assist the client in becoming capable of seeing humor in more of his/her daily life; promote this expansion through various means (e.g., increase his/her use of humor, telling jokes), assigning the client to watch one or two comedy movies each week.
  • Assist the client in applying stress management skills to his/her everyday life.
• Connect with sources in your social network who support your therapeutic changes.
  • Assess the client's social support network and encourage him/her to connect with those who facilitate or support the client's positive change.