Cognitive Behavioral Therapy, Self-Efficacy, and Depression in ...

Cognitive Behavioral Therapy, Self-Efficacy, and Depression in ...

• Chronic pain is a common, complex, disabling

condition (Chen, Wong, & Chu, 2004)

Depression is often part of the symptom

picture of chronic pain (Chen et al.; Thorn, 2004)

• Poor self-efficacy can complicate the struggle

with self-management of both problems

(Arnstein, Caudill, Mandle, Norris, Beasley, 1999;Turk, 2003; Wells-

Federman, Arnstein, Caudill, 2002; Wells-Federman, Arnstein,

Caudill-Slosberg, 2003)

• There is evidence that Cognitive Behavioral

Therapy (CBT) can improve self-efficacy and

depression in persons with chronic pain (Bennett

& Nelson, 2006; Chen et al., 2004; Turk, 2003; Wells-Federman et al.,

2002; Wells-Federman et al., 2003)

• The purpose of this evidence based project

was to explore the role of CBT focused groups

on self-efficacy and depression in persons

with chronic pain at the 3-week Pain

Rehabilitation Center (PRC).

• 3-week intensive, outpatient,

multidisciplinary pain rehabilitation program

at Mayo Clinic

• Helps persons with chronic pain improve

adaptation to and management of pain

• PRC is cognitive behaviorally based yet there

are no CBT groups in the current program

• CBT project added specific CBT concepts of:

• Identifying relationships among thoughts, moods,

physiology, and behaviors

• Identifying and challenging maladaptive thought


• 6 one hour groups added in the 3 – week program

• Formal Permission gained from Mayo Dept. of

Psychiatry and Psychology

• Winona State University and Mayo Institutional

Review Board approval obtained prior to


• Persons with chronic pain admitted to PRC from

October-December, 2009

• Data entry staff approached admitting patients

to complete the Center for Epidemiological

Study Depression Scale (CES-D; Radloff, 1977)

• CES-D scored 0-60 with persons scoring ≥ 27

approached by data entry staff, myself, or

data collection persons to consent for this


• After consenting completed the Pain Self-

Efficacy Questionnaire (PSEQ; Nicholas, 1989)

• PSEQ scored 0-60 with higher scores

indicating higher pain self-efficacy

• CES-D scores of persons admitted to PRC

from October-December, 2008, before the

CBT focused groups, made a comparison


• Data analyzed using Statistical Package for

the Social Sciences (SPSS)



• 51 persons

• 44 (86%) completed ≥ 3

CBT focused groups and

PRC program

• Admission and discharge

CES-D and PSEQ scores

were analyzed to assess

treatment outcomes



• 51 persons

• 43 (84%) completed the

PRC program

• Admission and discharge

CES-D scores were

analyzed to assess

treatment outcomes

Mean Pain Self-Efficacy Score


Figure 1. Efficacy of Pain Rehabilitation With CBT-Focused

Groups on Pain Self-Efficacy










There was a significant

increase in pain selfefficacy


participation in the

PRC program

(t (1, 44) = - 9.5,

p = < .001, d = 1.95)

Mean Depression Score








Figure 2. Efficacy of Pain Rehabilitation with CBT-

Focused Groups on Depression (CES-D)


2008 (no focused CBT groups)

2009 (with added focused CBT groups)


There was no significant

interaction between year

(2008 vs. 2009) and time

point (pre – post) on

depression suggesting

patients who participated

in CBT focused groups

improved equal to

patients who did not

participate in these


Patient response to:

88% (n = 15)

Very Satisfied

12% (n = 2)



“Rate your satisfaction

with the CBT focused


• Very Satisfied

• Somewhat Satisfied

• No Opinion

• Somewhat Dissatisfied

• Very Dissatisfied

• Patients experienced significant

improvements in pain self-efficacy upon

discharge from PRC suggesting self-efficacy

should be assessed in all PRC patients

• By adding CBT focused content without

lengthening programming patients can utilize

additional strategies to manage chronic pain

• Additional evidence-based projects and

research can be done to examine the role of

CBT interventions for persons with chronic

pain, and depression

• CBT focused groups will continue to be part

of PRC as a clinical practice improvement

• Patients were satisfied with CBT focused


• This evidence-based practice is well

supported in the literature and can be

implemented into patient care with

dedicated staff

• CBT focused groups can compliment

cognitive behaviorally based PRC programs

• Exploring the role of CBT focused groups on

self-efficacy and depression in persons with

chronic pain from a longitudinal perspective

may provide additional data about continued

utility of CBT

• With dedicated staff CBT focused groups

continue to be a part of the PRC program

• Watch for results of the entire project coming

out in Pain Management Nursing!

Arnstein, P., Caudill, M., Mandle, C.L., Norris, A., & Beasley, R.

(1999). Self-efficacy as a mediator of the relationship between

pain intensity, disability and depression in chronic pain patients.

Pain, 80, 483-491. doi: 10.1016/S0304-3959(98)00220-6

Bennett, R., & Nelson, D. (2006). Cognitive behavioral therapy for

fibromyalgia. Nature Clinical Practice Rheumatology, 2 (8), 416-

424. doi: 10.1038/ncprheum0245

Chen, P.P., Wong, T.C., & Chu, M.C. (2004). Chronic pain

management: A paradigm change. The Hong Kong Practitioner,

26,(6) 277-284. Retrieved on November 7, 2008 from British


Nicholas, M. Self-efficacy and chronic pain. (1989).

Unpublished tool. In paper presented at the annual

conference of the British Psychological Society, St. Andrews,


Radloff, L. (1977), The CES-D Scale: A self-report depression

scale for research in the general population. Applied

Psychological Measurement, 1 (3), 385-401.

Thorn, B. E. (2004). Cognitive therapy for chronic pain. New

York: The Guilford Press.

Turk, D. C., (2003). Cognitive-behavioral approach to the

treatment of chronic pain patients. Regional Anesthesia and

Pain Medicine, 28(6), 573-579. doi: 10.1016/S1098-


Wells-Federman, C., Arnstein, P., & Caudill, M. (2002).

Nurse-led management program: Effect on self-efficacy,

pain intensity, pain-related disability, and depressive

symptoms in chronic pain patients. Pain Management

Nursing, 3 (4), 131-140. doi: 10.1053/jpmn.2002.127178

Wells-Federman, C., Arnstein, P., & Caudill-Slosberg, M.

(2003). Comparing patients with fibromyalgia and chronic

low back pain participating in an outpatient cognitivebehavioral

treatment program. Journal of Musculoskeletal

Pain, 11(3), 5-12.

doi: 10.1300/J094v11n03_02

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