By Anne C. Dobmeyer, Ph.D., ABPP
Sept. 30, 2020

U.S. Army photo

Behavioral health consultants (BHCs) in the Military Health System have been trained to provide brief cognitive behavioral therapy for pain (BCBT-P) to primary care patients with pain. The aim of this treatment is to help patients develop adaptive coping skills so they gain a greater sense of control over their lives and their pain. Feedback from patients has been positive, with some patients requesting additional assistance. However, BHCs may find that a subset of patients have difficulty remaining engaged in care. BHCs may find themselves wondering:

"Although some patients with pain have stayed engaged in BCBT-P until they started using some new pain management strategies and their functioning began to improve, others have disengaged after just one or two appointments, even though they haven't yet shown much benefit. What strategies could help improve their engagement in care?"

Consistent with the primary care behavioral health (PCBH) model of integrated care, BHCs work with patients until symptoms or functioning begins to improve and there is a plan in place for continued improvement. For patients with chronic pain, there is no one "magic" number of BCBT-P appointments for everyone; rather, the treatment is flexibly designed to allow patients who need more care to receive more care. Of note, there is no evidence that just one or two BCBT-P appointments is effective for most patients with chronic pain. It is recommended that patients complete a minimum of three BCBT-P modules. Others will need more; there are seven modules available which cover goal setting, activity pacing, relaxation training, cognitive coping, and developing a pain action plan.

BHCs may face challenges in keeping the patient with pain engaged in care. BHCs can use a number of strategies to help keep patients with pain moving forward with BCBT-P rather than stopping care before the desired benefits have been reached. Examples of such strategies include:

• Setting the expectation during the initial visit that the patient will attend a minimum of three BCBT-P visits, but that many patients benefit from learning further skills and there are seven modules that can be covered over time.
• Communicating realistic expectations for rate of improvement, particularly the idea that it may take some time before the patient begins to see benefits from using newly learned skills. Stopping too early risks missing out on later gains.
• Consistent with measurement-based care, reassessing symptoms to provide patients with feedback on how their pain and functioning are (or are not) improving, and using this information to encourage continued care when needed.
• Using motivational interviewing approaches with patients who seem ambivalent about continuing with BCBT-P to increase willingness to remain engaged in care.
• Offering virtual follow-up appointments, when appropriate, to reduce barriers to continued care.
• Suggesting that face-to-face appointments be scheduled on the same day the patient needs to come to the clinic for another reason. This added convenience may increase willingness to attend additional BCBT-P appointments.
• Discussing with your clinic's primary care pain champion and pain care coordinator (PCC) whether the PCC could assist with tracking patients' care and contacting them if they have disengaged early from care.
• Recommending to each patient's primary care manager (PCM) that in future visits they encourage continued use of pain management strategies learned in BCBT-P and consistently reinforce the message that non-pharmacological pain management approaches like BCBT-P are an important part of improving life despite the continued presence of pain.
• Identifying upcoming PCM appointments of patients who have discontinued BCBT-P early. Touch base with the PCM the morning of the scheduled appointment and ask the PCM to recommend re-engaging with the BHC and offering a same-day BHC appointment.

Learn more about primary care behavioral health and the role of BHCs in managing pain and a variety of other conditions on the Psychological Health Center of Excellence website.

Capt. Dobmeyer is a U.S. Public Health Service psychologist in the Primary Care Behavioral Health branch at the Psychological Health Center of Excellence. She specializes in clinical health psychology and the integration of behavioral health services into primary care clinics within the Department of Defense.