Cognitive Behavior Therapy for Pain Management

CBT Therapy for Pain Management

Psychological Reactions to Pain

Pain is an essential biological function that signals damage in the body, prevents further damage by limiting mobility of the affected area and promotes healing. Pain can become chronic as a result of abnormal healing, additional damage or failed medical interventions. Once pain is chronic, it is no longer a useful biological function, but has negative physical and psychological effects on the sufferer. Very often, medical interventions cannot resolve chronic pain, which results in an increased need for pain management strategies. Psychological interventions for pain target a variety of domains including physical functioning, mood, cognitive patterns, quality of life, and pain medication use. As such, they are useful additions to any medical treatment for pain.

From a psychological point of view, recurrent pain affects an individual’s cognitions, mood, daily functioning, and increases vulnerability to depressive symptoms, anxiety, and Post-traumatic Stress Disorder (PTSD).  Chronic pain can also contribute to higher levels of disability, obesity, sleep problems, fatigue, and pain medication abuse. Due to the many negative symptoms associated with chronic pain, it is important to understand the three main psychological mechanisms related to pain that are suitable targets for intervention.

Pain catastrophizing refers to the magnification of the negative effects of pain, rumination about pain, and feelings of hopelessness in coping with pain. It also contributes to lower perceived levels of control over pain, lower social and emotional functioning, poorer coping and lower quality of life in the sufferer.

Pain-related fear is characterized by fear of injury or worsening of symptoms by performing activities that trigger pain. Pain-related fear is associated with lower physical functioning (increased disability) and quality of life. It also results in more passive, avoidant behaviors that can further increase disability and pain.

Pain acceptance refers to engaging mindfully in the present moment, nonjudgmentally acknowledging pain, stopping negative behaviors to try to stop the pain, and living a richer life despite the presence of pain. The two main benefits associated with pain acceptance are the willingness to experience pain, which lowers negative emotional reactions to pain; and continued engagement in valued activities, which increases positive emotions. Pain acceptance is the main target for mindfulness- and acceptance-based psychological therapies. 

Behavior Therapy

According to this theory, when individuals avoid painful behaviors, they actually contribute to the maintenance of chronic pain and depression. Therefore, the goal of behavior therapy is to gradually increase adaptive behaviors and decrease pain-avoidance behaviors. Through in vivo exposure therapy, individuals gradually engage in painful behaviors and when these behaviors are performed without serious negative consequences, they learn that their expectations about the consequences of physical movement and pain are unrealistic. As a part of this therapy, client and therapist develop a fear hierarchy including all forms of movement or situations the individual wants to avoid, and the client performs all those activities in a graded manner. Behavior therapy for chronic pain can be effective in reducing pain, and pain catastrophizing; as well as pain-related anxiety, depression and fear.

Cognitive-Behavioral Therapy (CBT)

CBT for pain aims to develop coping skills to manage pain and improve psychological functioning. Such skills can include structured relaxation, behavioral activation, e.g., scheduling of pleasurable events, assertive communication, and pacing of behaviors to avoid exacerbation of pain. CBT also targets maladaptive beliefs about pain by identifying thoughts and beliefs that are unhelpful with regards to pain and change them into more helpful ones that help increase positive functioning. CBT is the current gold standard in psychological pain management. CBT is also associated with reduced pain catastrophizing, disability, and longer-term improvements than medical treatment alone.

Mindfulness-Based Stress Reduction (MBSR)

MSBR is a protocol that includes meditation that was developed in Eastern philosophy and recently adopted as a Western intervention that enhances awareness and acceptance of physical and psychological sensations and disconnects psychological reactions from the physical sensations of chronic pain. In MSBR individuals learn mindful awareness and meditation, which help them view pain as simply a sensation, an experience that is not necessarily an indication of an underlying problem that needs to be attended to immediately. When an individual learns to recognize sensations and thoughts as something familiar, they are able to ameliorate their maladaptive responses to the experience of pain. Some advantages of MSBR are increased tolerance to pain, reduced rumination about pain, and increased mindful awareness and acceptance of pain. As part of MSBR, individuals commit to a practice of daily meditation and mindfulness and adopt a nonjudgmental attitude towards thoughts that creates emotional distance from thoughts. Unlike CBT, MSBR does not prescribe particular goals, only nonjudgmental observation.

Acceptance and Commitment Therapy (ACT)

ACT promotes an approach that emphasizes that thoughts do not need to be changed, instead only acknowledged and accepted as mental events. Acceptance of thoughts and emotions as simply mental events increases the individual’s ability to stay present and aware of personally relevant psychological and environmental factors. So individuals are able to adjust their behavior in a way that is consistent with their goals and values instead of just focusing on immediate relief from thoughts and emotions. ACT creates awareness and acceptance of pain, reduces focus on immediate pain relief and increases beneficial behavioral functioning. ACT focuses on goals and values as the impetus to direct behavior. It can effectively increase sufferers’ quality of life, self-efficacy while reducing depressive or anxious symptoms.

Both MSBR and ACT promote the acceptance of pain instead of emphasizing strategies to try to control pain. They both increase sufferers’ quality of life and well-being as well as engagement in more pain-independent activities.

Psychotherapy Pain Management Reference

Sturgeon, J.A. (2014). Psychological therapies for the management of chronic pain.Psychology Research and Behavior Management, 7, 115-124.