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Appendix
Complementary & Alternative Medicine with
Cognitive-Behavioral Therapy

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In the practice of Western medicine, individuals suffering from chronic pain often seek medical care with the hope of obtaining a specific diagnosis and curative treatment. When a curative treatment is not available, patients who have chronic pain frequently expect a prescription for analgesic medications ("painkillers") for pain relief. Unfortunately, specific diagnoses for most chronic pain problems are difficult to make, and treatments are rarely curative. Moreover, although analgesic medications can be effective in relieving acute pain in the short term, their utility for treating chronic pain is controversial and efficacy is, at best, marginal. For example, in a recent review of the efficacy of various treatments for patients who have chronic pain, it was noted that the average pain reduction for patients placed on long-term opioids is only 32% (Turk, Loeser, & Monarch, 2002). In addition, anticonvulsants, tricyclic antidepressants, and topical preparations (considered the treatment of choice for neuropathic pain) seldom produce pain reductions to below a rating of 4 on 0 to 10 numerical scales. Turk (2002, p. 355) concluded that "none of the currently available treatments eliminates pain for the majority of patients." Thus, despite the availability of multiple biomedical treatments for chronic pain, there remains ample room for additional, and perhaps for some patients even more efficacious, treatments.

Psychological Interventions for Pain Management
Cognitive-behavioral therapy (CBT) and other psychological interventions provide a viable alternative to traditional Western biomedical pain treatments. A growing body of research supports their efficacy for helping patients better manage chronic pain (e.g., Keefe, Abernathy, & Campbell, 2005; Morley, Eccleston, & Williams, 1999). However, like more traditional biomedical-focused pain treatments, psychological interventions are not universally effective (McCracken & Turk, 2002).

Furthermore, psychological interventions are not without their limitations. First, in order to be successful, they require significant effort and motivation from the patient (Jensen, Nielson, & Kerns, 2003). These treatments also tend to be time-intensive (10 or more 1-hour individual or group sessions is not unusual), and they usually require significant practice of the cognitive and behavioral management skills outside the treatment sessions. In addition, some patients who have chronic pain are so wedded to the traditional medical model, in which treatments are done "to" them and not by them, that they may have little interest in treatments that require their own efforts. Many such patients who desire a biomedically focused treatment will not participate in or follow through with psychologically based therapies such as CBT.

Along these lines, there may be a subset of patients who are particularly skeptical, rational, analytic, and hyposensitive to the emotional somatic component of psychosocial threats (Wickramasekera, 1998). Such patients tend to be reluctant to examine the cause of negative emotional somatic information and instead tend to search for physical explanations of and physical solutions for their distress. When these patients are referred for psychological treatment (for a pain problem), they may not attend the sessions or follow through with homework assignments or practice recommendations that are often a part of these psychological approaches. One reason for this apparent resistance may be the belief that seeing a psychologist for pain problems amounts to an admission that their pain is "in the head" and not real.

Complementary and Alternative Medicine
Complementary and alternative medicine (CAM) has been defined as a "diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, satisfying a demand not met by orthodoxy, or diversifying the conceptual frameworks of medicine" (Ernst, 2000, p. 252). According to the National Center for Complementary and Alternative Medicine, CAM includes "treatments and healthcare practices not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies" (Arnold, 1999, p. 1104). CAM encompasses both nontraditional treatments used in association with conventional Western medical practices as well as alternative medical interventions intended to replace traditional Western medical practices (Chiappeli, Prolo, & Cajulis, 2005).

CAM interventions have been increasing in popularity over the past two decades because of dissatisfaction with traditional Western medicine, the availability of information on the Internet, the influence of marketing forces, and the desire of patients to be more actively involved in their own medical decision making (Engel & Straus, 2002). Eisenberg and colleagues (1998) estimated that the U.S. public spent between $36 billion and $47 billion on CAM treatments in 1997. A recent U.S. national health survey of 31,044 adults found that 36% of the population surveyed used CAM therapies during the previous 12 months (Barnes, Powell-Griner, McFann, & Nahin, 2004). This percentage increased to 62% if prayer for health reasons was included in the definition of CAM. Back pain, neck pain, and joint pain are among the problems for which CAM therapies most commonly are used (Barnes et al., 2004).

In addition to traditional psychological treatments, we frequently use two CAM modalities: cranial electrotherapy stimulation (CES) and self-hypnosis training. CES involves "the application of a small amount of current, usually less than one milliampere, through the head via ear clip electrodes" (Kirsch & Smith, 2000, p. 85). The CES device we use, called "Alpha-Stim," has been approved by the U.S. Food and Drug Administration (FDA) as a treatment for depression, anxiety, and insomnia (Lichtbroun, Raicer, & Smith, 2001). On the basis of the finding that patients who have chronic pain frequently have comorbid affective disorders, CES began to gain popularity as an adjunctive intervention for pain management in the 1990s.

The mechanism(s) by which Alpha-Stim produces effects is not fully known. However, on the basis of previous and ongoing studies, it appears that the Alpha-Stim microcurrent waveform activates particular groups of nerve cells that are located at the brainstem, a site at the base of the brain that sits atop the spinal cord. These groups of nerve cells produce the neurotransmitters serotonin and acetylcholine, which can affect the chemical activity of nerve cells that are both nearby and at more distant sites in the nervous system. In fact, these cells are situated to control the activity of nerve pathways that run up and down the spinal cord to the brain. By changing the electrical and chemical activity of certain nerve cells in the brainstem, Alpha-Stim appears to amplify activity in some neurological systems and diminish activity in others. This neurological "fine tuning," called modulation, occurs either as a result of or together with the production of a certain type of electrical activity pattern in the brain known as an alpha state, which can be measured on brain wave recordings (called electroencephalograms [EEGs]). Such alpha rhythms are accompanied by feelings of calmness, relaxation, and increased mental focus. The neurological mechanisms that are occurring during the alpha state appear to decrease stress effects, reduce agitation and stabilize mood, and control both sensations and perceptions of particular types of pain. These effects can be produced after a single treatment, and repeated treatments have been shown to increase the relative strength and duration of these effects. In some cases, effects have been stable and permanent, suggesting that the electrical and chemical changes evoked by Alpha-Stim have led to a durable retuning back to normal function (Kirsch, 2006).

A small, but growing, body of controlled studies has reported on the efficacy of CES in reducing pain in patients who have fibromyalgia, tension headaches, spinal pain, dental pain, and unspecified chronic pain (e.g., Kirsch & Smith, 2000; Lichtbroun et al., 2001). For instance, in a double-blind, placebo-controlled study in which 60 randomly assigned fibromyalgia patients either were given three 1-hour-daily CES treatments, three 1-hour-daily sham CES treatments, or were held as wait-listed controls, treated patients showed significant improvements in pain, sleep, well-being, and quality of life and no placebo effect was found among the sham-treated controls (Lichtbroun et al., 2001). In another double-blind study in which 50 patients (30 receiving real CES and 20 receiving sham CES) were randomly assigned to receive different dental procedures, 24 of the 30 patients (80%) who received CES were able to undergo dental procedures without other anesthesia, while 15 of the 20 (75%) sham CES patients requested anesthesia (Clark et al., 1987). Our own double-blind placebo control pilot study on central neuropathic pain (below the level of injury) associated with spinal cord injury indicated significant reduction in pain intensity post session that was greater for the active CES treatment than the sham CES treatment (Tan et al., 2006). Although the mechanism(s) of action of CES on pain is still unclear, it is generally believed that the effects are mediated through a direct action on brain activity in the limbic system, hypothalamus, and/or reticular activating system. It also has been suggested that CES reduces anxiety and depression, thereby indirectly elevating the pain threshold (Kirsch & Smith, 2000). In addition, CES (and self-hypnosis training) can serve a useful "Trojan horse" function to persuade patients to become involved in psychologically based interventions. A practical feature of CES is that a psychologist simultaneously can carry out psychotherapy while the patient is "hooked up" to the device. Once patients learn that they can modify pain with changes in brain activity by using CES, they may become more willing to consider other treatments that alter brain activity, such as CBT.

Providing self-hypnosis training alone, or in conjunction with CBT and other psychological therapy, is a common practice for many psychologists. In Handbook of Hypnotic Suggestions and Metaphors (Hammond, 1990), the following hypnotic strategies and techniques for managing pain are described in detail: unconscious exploration to enhance insight or resolve conflict, creating anesthesia or analgesia, cognitive-perceptual alteration of pain (and pain behavior), and decreasing awareness of pain (distraction technique). In addition to these hypnotic approaches to pain management, we use the mind-body healing approach of Rossi (1993). In this latter approach, hypnotic suggestions can be given during the session for the patient to regress and access past learning, memory, and experience. As an example, a patient who had intractable headaches not amenable to conventional treatment was asked to regress and access memory that would help her manage her pain. While in a hypnotic state, she recalled several incidents of her first-grade teacher’s "knocking" her on the head with a pencil when she was not able to answer questions. The experience was very embarrassing, and she kept it to herself all her life. This moment of awareness and insight led the patient to report in a subsequent session that her headaches no longer were bothering her.

There is a growing body of research suggesting that hypnosis is an efficacious treatment for acute procedural pain and chronic pain conditions (Patterson & Jensen, 2003).A meta-analytic study examining the effect of hypnosis for pain reduction found that it offered considerable pain relief for 75% of the populations included in the analysis (Montgomery, DuHamel, & Redd, 2000). Hypnosis generally has a significantly greater impact on pain reduction as compared to no treatment, medication management, physical therapy, and education/advice (Jensen & Patterson, in press).
- Tan, Gabriel; Alvarez, Julie & Mark Jensen; Complementary and alternative medicine approaches to main management; Journal of Clinical Psychology; Nov 2006; Vol. 62; Issue 11.

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