Psychological Management of Chronic Pain Workshop

PSYCHOLOGICAL
MANAGEMENT
OF CHRONIC
PAIN
Dr. Umi Adzlin Silim
Psychiatrist
HKL
9 APRIL 2017

A bigger picture
• Understanding Chronic Pain
• Building Therapeutic Relationship & Giving
Empathy
• Multimodal Management: The Psychological
Intervention
• Evidence of Effectiveness (Optional)

PAIN
• Pain is defined as “an unpleasant sensory and
emotional experience associated with actual
or potential tissue damage, or described in
terms of such damage. (International
Association For The Study Of Pain, IASP).

CHRONIC PAIN
• Chronic pain is a chronic disease of the
nervous system. It is defined as pain longer
than expected, anything from 3 months to
years despite treatment.

When pain is acute, many contributors (active at same time) affect pain.
How
much
pain?
Mood:
Nervous System
Signals from injured part sent to
the brain can modify this input
Behaviours:
Attention:
Importance (thoughts):
Environmental influences:
Memory/learning:
In acute pain, the pain is due to a new injury or a noxious stimulus
Slides courtesy of Aida Farhana Suhaimi, Clinical Psychologist, Hospital Putrajaya

When pain is chronic – same processes active, but changes is central
nervous system (brain and spinal cord) add to the problem.
How
much
pain?
Mood:
Central Nervous System
Original injury healed but
Central sensitization processes
activated (harmless signal felt as
pain)
Behaviours:
Attention:
Importance (thoughts):
Environmental influences:
Memory/learning:
In chronic pain, the pain is still real, but it is not due to new injury or harm

SENSITIZATION
PERIPHERAL SENSITISATION
• ‘The Sunburn’
• Reversible with no lasting effects
CENTRAL SENSITISATION
• Nerves in the spinal cord gets sensitised
• Not reversible

CENTRAL SENSITISATION
• Feeling more pain, quite out of proportion,
when doing something that should not be
painful.
– Neuropathic pain – damage or changes in the
nerves
– Nociceptive pain – damage to body tissues
• Real pain, may think there is something
seriously wrong.

CHRONIC PAIN
Important differences between chronic pain and acute
pain:
• Chronic pain is long term pain and acute pain is short term
• Chronic pain is just as real as acute pain, but it is not due to
new harm or re-injury
• Chronic pain is maintained by changes in the central nervous
system
• At present, these changes cannot be reversed although some
medications can dampen the effects for some people
• The focus of chronic pain is managing it, not relief

What A Patient Have
Gone Through?
• Have seen various doctors
• Have done various
investigations
• Have undergone multiple
procedures
• Have been on various
medications
• PAIN PERSISTS

Exploring Patient’s Experience – 1/3
What would you do when you notice you have pain in the
early days?
Most likely you will reduce or stop activities and take rest or
see a doctor.
What did your doctor recommend?
Your doctor may prescribe you painkillers, do multiple
investigations, refer you to physiotherapist or other
specialists.
What did your specialists do?
Your specialists from various discipline may do further
investigations, prescribe more medications and may offer
you surgery and other interventions.

Alongside that, what happen to your pain?
Your pain may be up and down or still persist, you may have
side effects of treatment and it becomes a vicious cycle.
What happen to your functioning?
You may have reduced your activities, your function will be
worsening, you may lose your job and you face financial
stress.
What happen to your relationship?
You face changing relationship. It is hard to make people
understand, you feel angry that people do not believe in you.
You may have to put a mask in front of others and it can be
exhausting. You feel isolated.

What happen to your feelings?
You may be feeling hopeless, depressed and anxious.
What happen to the way you think?
You may find a lot of changes of thinking. You think it is not
safe to do activities. You are fearful of more injury or further
damage. You may avoid activities.
What happen to your body?
Your body will be more stressed, weaker, losing its fitness and
decompensating. It create more and more layers of sufferings

What is the first thing you do when your chronic
pain patients talk about their difficult
experience & emotions?
A. Give advice eg. to be more patient, to have
more acceptance
B. Quickly find solutions to fix problem eg do
investigations, increase medications or make
referrals
C. Provide them emotional support (Yes, I know
how to do this)
D. Provide them emotional support (Oh, am I
sure how to do this?)

How to Response to
Your Patient?
• How to Say It Right?
• Building Therapeutic
Relationship
• Emotionally Supportive
• Showing Empathy
• Prevent Complaints too

Providing Emotional Support
• Psychological First Aid
• Showing empathy
• Emotional Validation
– Being With the Emotions
– Accurate Reflection
– Naming The Emotions
– Normalizing

Emotional Validation:
Accurate Reflection
• “It is a difficult experience and a long journey
for you”
• “Ini adalah satu pengalaman yang sukar yang
telah anda lalui dalam satu tempoh yang
panjang”

Accurate Reflection
• “Sounds like struggling with pain and side-
effects of treatment has become a vicious
cycle for you”
• “Apa yang saya dengar adalah anda
menderita kesakitan dan mengalami kesan
sampingan rawatan dan ini menerukkan
keadaan anda”

Naming The Emotion
• “You must be feeling very worried that despite
treatment, you still have pain on & off, good
days and bad days”
• “Anda mesti berasa bimbang kerana
walaupun dengan rawatan, anda masih kerap
merasa sakit, berulang kali”

Naming Emotion
• “It must be disappointing when you think that
you have exhausted all options and reach a
dead end”
• “Anda mesti kecewa apabila anda fikir anda
telah mencuba semua rawatan yang ada
tetapi masih menemui jalan buntu”

Normalizing
“It is a normal journey that people with pain
go through to ensure that it has been
adequately investigated and all treatable
causes being treated”
“Apa yang anda lalui adalah sesuatu yang
normal untuk memastikan semua ujian
dilakukan dan apa yang boleh dirawat, telah
dirawat.”

Normalizing
“You have tried many options, and you know
some is not for you. Many people reached this
situation and feel like you do… ”
“Anda telah mencuba pelbagai rawatan, dan
anda tahu sebahagiannya tidak sesuai untuk
anda. Ramai pesakit melalui pengalaman ini
dan mengalami apa yang anda rasakan…”

What is the first thing you do when
your chronic pain patients talk about
their difficult experience & emotions?
A. “Sabar…Bila sakit ni kita kena banyak-banyak
sabar”
B. “Saya faham apa yang puan rasa…”
C. “Baiklah, Saya akan naikkan ubat puan dan
rujuk kepada…”
D. “Saya pasti puan sangat bimbang bila sakit
masih tak baik walaupun semua rawatan
sudah diberikan….”

WHEN CHRONIC PAIN BECOMES A PROBLEM
(Nicholas, M et al in Manage Your Pain)
CHRONIC PAIN
EXCESSIVE SUFFERING
Loss of job,
financial
difficulties,
family stress
Long term use
of analgesics,
sedative drugs
Repeated
treatment
failures
Unhelpful
beliefs and
thoughts
Reduced
activity
Side effects
(e.g. stomach
problems,
lethargy)
Feelings of
depression,
helplessness,
irritability
Physical
deterioration

CHRONIC PAIN
COMES FROM THE BRAIN
(central sensitization)
AND CAN BE RETRAINED

RETRAIN THE BRAIN AND THE
NERVOUS SYSTEM
SO, TO MANAGE CHRONIC PAIN….

MEDICAL
THOUGHTS
AND
EMOTIONS
DIET EXPLORING
PAIN
PHYSICAL
ACTIVTY
PAIN RELIES ON
CONTEXT
MORE STRESS,
MORE PAIN
MOVING WITH
NO FEAR
AND NOT
CONTROLLED BY
PAIN

PSYCHOLOGICAL INTERVENTION IN
PAIN MANAGEMENT (Nicholas, M in APAPT Program)

SETTING GOALS
RECOGNISING AND
OVERCOMING
OBSTACLES TO
CHANGE
CHALLENGING
UNHEPLFUL
THOUGHT PATTERNS
RELAXATION AND
ATTENTIONAL
TECHNIQUES
PROBLEM SOLVING
INTERACTING WITH
THOSE AROUND YOU

PSYCHOLOGICAL INTERVENTION:
PROVIDED AS PART OF A ‘PAIN MANAGEMENT PACKAGE’
COGNITIVE AND BEHAVIOURAL THERAPY
THOUGHTS
BEHAVIOUR FEELINGS

BEHAVIOURAL THERAPY
SETTING GOALS
PACING
RELAXATION & ATTENTIONAL SKILLS

BEHAVIOURAL THERAPY
• Changing the ways they do things, which in
turn help their mood and alter the way they
think

SETTING GOALS
PECIFIC – Concrete, knowing that they have achieved the goal.
Most effective goals are those that can be described easily.
EANINGFUL – goals that they really want to achieve
CHIEVABLE – can be reached through their own effort
EALISTIC – within financial means, appropriate for their age,
skills, education, family situation, physical condition and can
be done despite pain.
IMED – making sure there is a duration to achieve the goal
Have a number of goals - to work on different areas of life

LONG TERM GOALS
Household Chores
Family Activities
Social Activities
Recreation/sport
Education
Hobbies/interests
Work
Other
SETTING GOALS

Example: Setting Goal
• Long term goal: Travelling by car to
hometown
• Setback: Unable to sit for long time
• Short team goal: Increase sitting tolerance
using pacing technique

Example: Smart Goal
Specific can be described easily.
 Eg: A son wants to travel by car to hometown in May
Meaningful goals that patient wants to do and felt accomplished upon completing it.
 He can visit his parents as they are too ill to travel to see him and
accomplished his duty as son.
Achievable can be reached through own effort
Realistic within financial means, appropriate with age, skills, education, family situation,
physical condition and can be done despite pain.
Timed Making sure there is duration to achieve the goal

RECOGNISING AND OVERCOMING
OBSTACLES TO CHANGE
Important that you first work out the problems you
want to deal with and the goals you want to achieve
Information
and
reassurance
Do it.
Relaxation
techniques
and challenge
unhelpful
thoughts
Time and
Motivation

PACING
• Over time, as more activity resulted in more
pain, patient tends to rest more, leading to
weaker muscle and stiffer joint. With this,
exercise become more difficult and some
activities might seem impossible.
• To maintain patient in fair level of activity,
pacing is important to help patient develop
good activity tolerance gradually.

Using pacing to overcome the effects
of Chronic Pain on Activities
A Common Pain – Activity Interaction
Overactivity More Pain
Easing of Pain Rest/frustration

Baseline (where to start) and pacing
• Determine how much they can do at the
moment – baseline
• Do it in several occasions rather than just one
• Baseline should be within the limits of their
present pain tolerance, not pushing it to the
maximum
– progress be reviewed
regularly

Overactivity/underactivity cycle
Pain Aggravated
Pain Aggravated Pain Aggravated
Overdo
Activities
Overdo
Overdo
rest
(Pain lessens)
high
rest
(Pain lessens)
ACTIVTY
low
TIME (DAYS OR WEEKS)

Principles of Pacing : an essential
technique for mastering chronic pain
1. Take frequent, short breaks
2. Gradually increase the amount you do
3. Break up tasks into smaller bits
Guidelines for pacing
1. Work out what you can manage now
2. Work out your starting point or baseline
- Start 20% below baseline
3. Decide on a realistic build-up rate
4. Write your plan down and record your progress

Work out what you can manage now
• Decide on the target activity which patient is
comfortable with at current level.
• Start on activities which is easier
• Measure by timing or counting
• Take the average timing or counting of the
activity as baseline
• Eg: Patient can walk for 8 minutes before pain
occur in Trial 1, 5 minutes in Trial 2 and 8 minutes
on Trial 3. So, average baseline for his walk at
current state is 7 minutes.
Handbook of Psychological Intervention of Chronic Pain Manaagement, KKM, 2017

Work out at the starting point
• Work out the from the baseline
• Start below baseline to ensure patient will not
experience the pain while doing the activity
• It is recommended to start at 20% below
baseline. (Using eg above for baseline of 7
minutes, the starting point is approximately 5
minutes).
• So patient should walk for 5 minutes and then
rest before resuming the walk again.

Decide on Realistic Build-up Rate
• Decide on realistic build up rate
• Try to build up the rate of activity at gradually
regardless the pain.
• Eg: patient is comfortable with walking 5
minutes for 2-3 days, they can then lengthen
the duration to 7, 9, 11 minutes and so on at
the same interval
• The build-up rate must be in accordance to
patient’s tolerance.

Write down plan and record progress.
• Important in monitoring patient’s progress.
• Determine the plan to build up rate for the
next day after completion of the activity.
• Progress will motivate and build up patient’s
confidence level

Additional hints for using pacing
1. Start on activities that are easier
2. For those activities that you cannot leave, it is
most important that you still try to pace yourself
as much as possible
3. Try to change your position regularly
4. Remember, it is all right to ask for help with
specific tasks now and then – everybody does it.
5. Keep to your targets and plans as much as
possible.
Pacing : an essential technique for
mastering chronic pain

Using pacing to overcome the effects
of chronic pain on activities
Pacing up your activity level (step by step)
‘GOOD DAYS’ ‘BAD DAYS’ ‘GOOD DAYS’
Baseline (starting point)
Pacing line
High
Low
TIME (DAYS OR WEEK)
Keep to the
plan despite
good/bad days

COGNITIVE THERAPY
• Examine the ways they think and how
thoughts affect their feelings
• Come up with alternative ways of looking at
the problem

CHALLENGING WAYS OF THINKING ABOUT PAIN
When worry grows into anxiety
(in the future)
Believe you have no control
Worry
PANIC!
Focus attention on unpleasant feelings
Lose confidence
Do something drastic
Get in a mess, take
tablets, overdo it
Avoid the situation
‘What if it gets worse?’
‘I feel terrible’
‘I can’t cope’
‘I’m useless, I can’t
do anything’
‘I’m a failure’

More Helpful Reactions to Increase Pain
Keep control (it’s what you do
that will count)
Recognise the problem and
keep calm
Focus on planning
(options)
My pain will probably
be quite bad for a
while, but I can calm
What can I do? What are
my options? I can stop for
a while, do my relaxing,
some stretches, go for a
short walk.
I can manage. I’ll take it a
step at a time.
I did that well
Your Old Way of Thinking
Worry
Focus attention on
unpleasant feelings
Believe you have no
control
Increased chance of success
More Confidence
Your New Way of Thinking
I know what to
do next time
CHALLENGING WAYS OF THINKING ABOUT PAIN

INTERACTING WITH OTHERS
Aggressive vs Passive vs Assertive
Communication

STRETCHING AND EXERCISING
PAIN
FURTHER INACTIVTY
PAIN ON MILD EFFORT
DECONDITIONING
LESS ACTIVITY
PAIN
(avoid activities)
PAIN ON MINIMAL EFFORT
FURTER DECONDITIONING
The Downward Spiral

STRETCHING AND EXERCISING
STARTING TO FEEL STRONGER AND
MORE IN CONTROL
STRENGTHENING ACTIVITIES
PAIN ON MINIMAL EFFORT
The Upward Spiral
START STRETCHING
REDUCED FEAR OF ACTIVTIES
ENDURANCE ACTIVITIES
IMPROVED CONFIDENCE
RETURN TO PRODUCTIVE ACTIVTIES

MAINTAINING CHANGES
• Those done best in the long term are those who
have kept up their pacing, relaxation and fitness
exercises plus other coping skills.
• Important points to keep in mind:
– Stay active in as many areas of daily life as possible
– Deal with setbacks or lapses and learn from them
– Take credit for every achievement
– Seek encouragement from others
– Work with the doctor

Reference
• Associate Professor Dr
Michael Nicholas
Clinical Psychologist within
the pain field since 1980
• Dr Allan Molloy
Anaesthetist
• Lois Tonkin
Senior Physiotherapist
• Lee Beeston
Senior Nurse in Pain
Management

EVIDENCE OF EFFECTIVENESS
REVIEW STUDIES

OTHER PSYCHOLOGICAL
APPROACHES AND CHRONIC PAIN

MULTIDISCIPLINARY APPROACH TO
MANAGE CHRONIC PAIN

ADAPT PROGRAM
Authors:
Dr Michael Nicholas
Dr Allan Molloy
Lois Tonkin
Lee Beeston

ADAPT PROGRAM
• Multidisciplinary approach intensive program
at the University of Sydney Pain Management
and Research Centre at the Royal North Shore
Hospital in Sydney (since 1994).
• Runs at the hospital
• Patients attend all day, Monday to Friday, for
three weeks

• Does not promise instant relief or does it
promise total relief in the future
• Instead, describes an approach to manage the
pain
• The program expects the patient to play an
active and on going role
ADAPT PROGRAM

• Whether it helps the patient to achieve their
goals will depend on several things.
• These include:
– How realistic their goals are
– How well they put the methods into practice
– How much they actually want to achieve their
goals
– How much support they have in their
environment, at home and work
ADAPT PROGRAM

Evidence of Effectiveness of ADAPT-
type treatments
• A cognitive behavioural treatment
• Not aimed at the underlying cause of pain, but
rather at reducing the impact of pain on the
person and their daily activities
• Addresses the person’s emotional state, their
range of daily activities, their sleep, and their
use of unhelpful medication.
• More than 30 studies of cognitive behavioural
treatments for chronic pain

Moving Towards Living With Pain
• There are evidence-based psychological
approaches to chronic pain.
• Treatment goal is not for cure but to live with the
pain.
• Self-management of chronic pain is about
learning new skills in managing pain.
– help reduce disability due to pain
– increase functioning
– minimise suffering on mood, anxiety, stress
– increase one’s quality of life.

“It is not about cure,
but living with pain”
• It may have taken you months to years to fix
and find cure for your pain and it must be very
disappointing to learn that cure is maybe
unlikely.
• Setelah berbulan/bertahun-tahun berusaha
untuk sembuhkan sakit tapi tidak Berjaya,
saya rasa ia mesti satu yang mengecewakan
untuk mengetahui yang kesembuhan memang
agak sukar dicapai.

• People may have told you that it is all in your mind.
Even though it is not clear why your pain lasted so
long, it doesn’t mean your pain is all in your mind. You
pain is real and maybe due to hypersensitization of
your nervous system.
• Mungkin ada orang yang pernah beritahu anda yang
sakit ini semua dalam pemikiran. Walaupun kita tidak
jelas mengapa sakit ini berterusan dan tidak dapat
hilang, tidak bermakna semua ini suatu yang hanya
dalam pemikiran, ia satu pengalaman yang benar-
benar anda alami dan mungkin berlaku kerana system
saraf yang terlampau peka/terlalu sensitive.

• Although it may be disappointing to accept that
there is no cure for your pain, but the good news
is there are lots of strategies that people has
learned and find it very helpful to cope with pain.
• Walaupun ia mengecewakan untuk menerima
yang sakit ini tidak dapat sembuh sepenuhnya,
namun ada banyak strategi yang boleh dipelajari
dan sangat berguna membantu anda menangani
kesakitan.

• It is not about cure, but about learning active self-
management strategies and making it a new habit of your
life to improve the impact of pain and improve your
functioning. It may be challenging in the beginning but the
more you have positive experience of managing pain the
more confident you will be.
• Kita tidak bermatlamatkan kesembuhan dari rasa sakit,
tetapi belajar menguruskan diri secara aktif untuk
mengurangkan kesannya kepada kehidupan dan
meningkatkan fungsi diri sehari-hari. Ia mungkin mencabar
pada peringkat awal, namun semakin anda mendapati
kesan yang positif, and akan semakin yakin untuk
menerusknannya.

RELAXATION
• Use it to calm self down, to help cope better
with pain
• It’s a skill – practice makes perfect
• Won’t stop the pain, but help to cope better
with pain

HYPNOSIS
• Like relaxation but performed by a the therapist to help
you calm
• Once relaxed, still awake, therapist will make
suggestions to help you take your mind off your pain
• Can be pleasant – BUT NOT THE CURE
• Only works for a short time
• Requires a therapist
• Offers no advantages over simply learning to relax

KEMAHIRAN PERNAFASAN TENANG
• Relaksasi adalah penting supaya lebih tenang,
badan menjadi lebih relaks dan meningkatkan
daya tumpuan. Pada mulanya, mungkin tidak
mudah untuk anda relaks. Namun, seperti
mana-mana kemahiran yang lain, anda akan
lebih mahir apabila anda kerap melakukannya
dan yakin ianya berkesan. Oleh itu, jangan
risau jika anda tidak mahir dalam cubaan
pertama. Teruskan Praktis! Praktis! Praktis!
Sumber: Program Tiara-Murni, Kementerian Kesihatan Malaysia, 2017

KENAPA PERLU TAHU TEKNIK
PERNAFASAN YANG BETUL?
Menjadikan kita lebih relaks.
Mengurangkan tumpuan negatif dan
tumpuan ke sesuatu yang lebih
relaks.
Relaksasi spontan. Mudah dan boleh
dilakukan di mana-mana sahaja.

PERNAFASAN TENANG
1. Tarik nafas perlahan-lahan melalui hidung menggunakan otot perut
untuk 4 saat.
2. Kemudian tahan nafas untuk 2 saat (sekiranya tidak membebankan).
3. Seterusnya, hembus nafas secara perlahan-lahan untuk 6 saat
melalui hidung (atau mulut).
4. Bernafas seperti biasa untuk 2 saat atau rehat sebentar sebelum
kitaran seterusnya.
INI SATU KITARAN PERNAFASAN TENANG.

PERNAFASAN TENANG

STRESS MANAGEMENT &
COPING SKILLS

Flip Your Lid:
Hilang Akal / Dikuasai Emosi
umiadzlin@gmail.com

Attentional Skills
• This technique involves distraction and
desensitisation methods. Even though these
techniques will not remove the pain
completely, it will help in reducing the pain.
This technique is recommended once the pain
starts to bother patient.

LIHAT
Hubungan Sosial
Lihat gambar-gambar orang yang tersayang (kenalan, ahli keluarga, binatang kesayang
Interaksi sihat di media social
Ilmu
Tonton tayangan atau video yang menyeronokkan
Tonton video yang boleh meningkatkan kemahiran
Belai Diri
Beli bunga dan letakkan tempat yang anda mahu lihat
Lihat majalah yang mempunyai pemandangan yang cantik.
Ugama
Tonton tayangan berunsurkan keagamaan
Renungi pengalaman atau kehidupan yang menginsafkan
Rekreasi
Duduk di taman dan lihat pemandangan sekeliling
Amati alam semulajadi yang cantik, tenang dan menggembirakan (hujan, air terjun,
pelangi, bintang dll).

DENGAR
Hubungan Sosial
Bergembira dengan ahli keluarga
Hubungi kenalan-kenalan untuk berkongsi pengalaman
Ilmu
Dengarkan segmen-segmen radio yang boleh meningkatkan ilmu pengetahuan atau
kemahiran
Dengar lagu atau tayangan bahasa asing, atau ilmu yang baru
Belai Diri
Beri kata-kata perangsang pada diri sendiri (“Ini semua hanya sementara” atau “Ini
pengalaman baru untuk saya”). Dengarkan lagu-lagu kesukaan yang boleh memberi
ketenangan, kegembiraan atau semangat
Ugama
Dengarkan buku-buku audio atau penceramah yang berunsurkan keagamaan
Dengarkan audio yang menenangkan seperti selawat dan zikir
Rekreasi
Duduk di taman dan dengar bunyi-bunyi alam semulajadi
Pasangkan irama yang menenangkan seperti bunyi derusan ombak atau air terjun

RASA
Hubungan Sosial Makan bersama dengan orang yang tersayang dan hargai kehadiran mereka
Ilmu Kembangkan rangsangan rasa dengan mencuba masakan baru atau resepi baru
Belai Diri Makan makanan kesukaan anda dan amati setiap gigitan dan kunyahan
Ugama Hubungkaitkan amalan pemakanan dengan kesihatan
Rekreasi
Sesekali mencuba restoran atau tempat makan yang tidak pernah di cuba, atau pergi
ke tempat yang disukai sebelum ini

SENTUHAN
Hubungan Sosial
Pegang dan belai orang tersayang
Nikmati sentuhan kaki, jari-jemari, rambut bayi/anak
Ilmu Pelajari ilmu sentuhan dan urutan
Belai Diri
Baring di atas cadar katil yang baru di basuh dan dipasang
Usap, dakap, sayangi setiap perubahan diri anda
Ugama
Bertasbih dan rasakan sentuhan pada jari-jemari anda
Mengamati sentuhan pada posisi-posisi ketika bermeditasi (contohnya yoga, bersujud
dll.)
Rekreasi
Terapung di dalam air dan rasakan ketenangan sentuhan air pada badan anda
Sentuh dan belai diri anda semasa mandian bunga, bahan semulajadi

Awful & Beautiful Behaviour
A A
A AA A
A A
B B
B B
B B
B B B B
B B

TAKE HOME MESSAGES
• Psychological Interventions for Chronic Pain
are effective (and evidenced-based)
• Techniques include behavioral therapy (goal
setting, pacing, relaxation & attentional skills);
cognitive therapy; stress management skills
and communication skills.
• Therapeutic relationship with good
communication & empathy is crucial.

Psychological Management of Chronic Pain Workshop

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Psychological Management of Chronic Pain Workshop