FAP-enhanced group therapy for chronic pain.

Abstract

There is a firm tradition of cognitive behavioral programs for chronic pain and structured treatments for training coping skills have been relatively successful with motivated and cooperative participants. However, what is being trained generally comes down to component skills and ways of thinking that have to be used by the client in complex real life situations. The aim of this paper is to illustrate how the principles of Functional Analytic Psychotherapy (FAP) can be applied in a group therapy program for people with chronic pain, using genuine in vivo occurrences of pain-related or stress-maintaining interpersonal behaviors of the participants during the group interaction. Functional analytic case conceptualizations of two participants with treatment resistant chronic pain are presented. The use of FAP-informed strategies during complex exchanges in the group is shown by means of vignettes. It is argued that FAP offers a way to make group therapy more relevant for real life problems and more effective for some people with treatment resistant pain. Key words: FAP; group therapy; chronic pain. A Radical Behaviorist Critique of Traditional Treatment of Chronic Pain. Chronic pain is often maintained as part of a series of vicious circles. Orofacial pain, for instance, can be related to spasms of the chewing muscles, which can be both the cause and the effect of a variety of factors including dysfunctional oral habits, changes in dental occlusion, continuous excessive contraction, and any combination of these. Increasing pain can provoke more muscular tension and vice versa, while muscular irritation may lead to more dysfunctional contraction, which again can increase irritation. Finally, months or years of suffering facilitate pain-focused lifestyles that on their turn help maintain the pain. Psychosomatic models (Melzak, 1998; Gramsa e Vikis-Freibergs, 1991) refer to the relation between a great array of stressors and physical changes like increased muscular tension or cumulating cortisol releases that can have destructive effects on tissues, laying the immediate basis of pain or leading with later stressors or minor injuries to disproportionably intense pain. In itself, pain may be a severe stressor and can be both the cause and consequence of maladaptive coping behavior. When the search for causes of chronic pain does not provide any therapeutic advantage, specific behavioral patterns related to the pain have been targeted. Applied behavior analytical (Fordyce, 1976) and cognitive behavioral programs (Turk, Meichenbaum and Genest, 1985) have been designed to reduce various types of chronic pain and to better coping with residual pain. The effects of structured group therapy have been well explored in both operant and cognitive approaches (Turner, 1988; Thorn, Boothby, Sullivan, 2002). However, there are patients who do not improve with traditional treatments. Departing from a radical behaviorist critique of group therapy it was our intention to go beyond the educational format of these approaches. From a functional analytic point of view, the skills acquired in traditional approaches are still very different from the target behavior, because they are maintained by other contingencies, like approval by the therapist or other group members. The contingencies that act in daily life are often completely different from those that act in treatment settings. What is being modified generally comes down to component skills and ways of thinking that have to be used by the client in complex real life situations. When the client uses the new skills in a real life setting, he or she will have to remember the steps learned during training to execute them, which means they will be functionally different from genuine interactions. The aim of the present paper is to illustrate through a number of vignettes the possibility of applying the principles of Functional Analytic Psychotherapy in a group therapy program for patients with chronic orofacial pain. …