Access to the PPM Journal and newsletters is FREE for clinicians.
Signup for PPM
19 Articles in Volume 20, Issue #4
20/20 with Dr. Nathaniel Katz: Pain Research and Future Therapeutics
A 20-Year Timeline: Pain Therapeutics and Regulations
A Comparison of the Alpha-2-Adrenergic Receptor Agonists for Managing Opioid Withdrawal
A Pain Assessment Primer
After the Task Force: A Conversation with Vanila A. Singh, MD
Ask the PharmD: Can opioids and benzodiazepines ever be used together?
Cognitive Strategies and Mindful Awareness for Integrative Pain Care
COVID: Clinical Considerations for Acute and Post-Infection Symptoms
Editorial: Fudin and Gudin Tackle Pain Care History – Asking, Have We Done a 180?
From Hands-On to Home-Based Care: Physical Therapy Undergoes a Paradigm Shift Due to Pandemic
MS-Related Pain and Spasticity: Are Cannabinoids an Option?
New Biological Agents for Psoriatic Arthritis: A Monoclonal Antibody Primer
Pandemic Presents Unexpected Opportunity to Embrace Multimodal Analgesia and the Integrative Care Team
Provider Perspective on Knee OA: Injections and RFA Options
Redefining the “Pain Specialist” of Today
Resident’s Corner: Climbing the Learning Curve in Pain Management
The Evolution of Pain Management: Experts Weigh In
Tips from the Field: How to Enhance Practice Efficiency
Tumor Necrosis Factor (TNF) Inhibitors: A Clinical Primer

Cognitive Strategies and Mindful Awareness for Integrative Pain Care

The expansion of cognitive-informed approaches provides more ways for HCPs to help patients change attitudes and beliefs about their pain.

In 2007, Kreitler and Kreitler developed a classification of psychological techniques for the treatment of pain specifically in chronic pain patients. The classification system is organized by components of pain distress, including cognitive, behavioral, sensory, and affective.1 Cognitive treatments aim to improve pain control by facilitating a change in patients’ attitudes toward their pain. The underlying assumption is that cognitions, or thoughts, and beliefs impact the experience of pain.

Cognitive behavioral approaches for pain integrate mindfulness, such as acceptance & commitment therapy (ACT), dialectical behavior therapy (DBT), and mindfulness-based cognitive therapy (MBCT). (Image: iStock: Kagenmi)

There are several psychological techniques informed by the cognitive component of pain. According to the original classification, these include psychoeducation, cognitive attitude-based therapy (CABT), cognitive coping therapy, and cognitive therapy (CT). This review expands this category to include psychotherapy approaches that integrate cognitive therapy and behaviorism, including cognitive-behavioral therapy (CBT), rational emotive behavioral therapy (REBT), and cognitive processing therapy (CPT).

This review also includes cognitive behavioral approaches that integrate mindfulness, such as acceptance & commitment therapy (ACT), dialectical behavior therapy (DBT), and mindfulness-based cognitive therapy (MBCT). The expansion of cognitive-informed approaches into pain management helps to evolve and improve upon traditional cognitive approaches, while also enhancing the pain practitioner’s therapeutic tool belt.

The following is a review of each type of psychotherapy for pain, its target patients, and a broad overview of its effectiveness for treating pain-related distress.



Didactic Information-based Techniques
Past research has recognized the difference between didactic information, or health education, and psychoeducation, and identified the need for separate patient education programming to complement existing chronic pain interventions. Coping is a state of being tolerant, minimizing, accepting, or ignoring things that cannot be controlled. These are skills acquired from psychoeducation through a cognitive route.2 Learning requires thinking, and learning has the potential to change thinking and behavior.3

Conversely, self-management is the activity people undertake to create order, discipline, and control in their lives. These are skills typically learned from the didactic information-based technique, or a health education program.4 Health education programming based on the biopsychosocial approach to pain management emphasizes the patient’s responsibility for self-management, and outcomes are improved when programs include pain education, wellness principles, and sound interventions.5

Pain Education Programs

Some hospital systems offer formal pain health education programs. For example, the Pain Education School program was developed at a midwestern VA Medical Center in 2009 to address the biopsychosocial, health education needs of veterans who suffer from chronic, noncancer pain.6 The goals of the program are to share basic principles of pain relief and prevention, provide education about pharmacologic interventions, and introduce services offering nonpharmacological interventions for relief of chronic or persistent, noncancer pain.7 Such an education-focused, professionally driven program assumes that if individuals are provided with adequate education, they will self-manage their illness.4

Therapeutic Neuroscience

Pain is complex, and new paradigms of pain – such as neuromatrix, nerve sensitivity, endocrine and immune responses to pain, neuroplasticity – have introduced the use of nonpharmacological options in the treatment of pain. However, patients continue to be focused on how pain works, and their interest appears to have a purpose.

According to the International Spine & Pain Institute, there is growing evidence that supports teaching patients more about the neurophysiology and biology of pain which allows for decreased pain, psychometric measurements, increased movement/function, and compliance with therapy. Therapeutic neuroscience education is predominantely oriented in physical therapy, but the programming is complemented by psychological concepts. It aims to reduce threat perception through education in order to shift patients away from disuse and disability.

Cognitive Attitude-based Therapy (CABT)

Pain management may be attained by shifting patients’ attitudes concerning the etiology of pain, diagnostic expectations, treatment expectations, and outcome goals. The underlying change mechanism of CABT asserts that enhancing positive attitudes or weakening dysfunctional beliefs can promote pain management. There are different inventories used to measure pain attitudes and beliefs, including the Pain Beliefs Questionnaire, the Survey of Pain Attitudes, Pain Information and Beliefs Questionnaire, and the Pain Beliefs and Perception Inventory.1 Providers can change patients’ attitudes about pain through group discussions, supplemental support materials, and explanatory models.8

Target Patients: Pain education programs have been shown to decrease pain intensity,9,10 improve pain knowledge, and change beliefs about pain.9-12 While research demonstrates that they make minimal changes in subjective pain experiences,10,13 pain education programs have been shown to create positive changes on depression measures.10,14 Further, therapeutic neuroscience education programs have been shown to decrease pain,15 improve pain beliefs,16 and improve cognitions, pain thresholds, and movement performance.17


Cognitive Coping Therapy

Patients’ beliefs about their pain has been shown to be a good predictor of their long-term rehabilitation.18 Pain management can be accomplished by promoting patient acquisition of adequate cognitive skills (eg, active problem solving, using coping self-statements, and humor) and forfeiture of inadequate cognitive skills (eg, catastrophizing and overgeneralization).1 Providers can accomplish these tasks by providing information, discussion, modeling, reinforcement, rehearsal, generalization to everyday life, and support for maintenance.19 Often, these cognitive coping strategies are implemented through Cognitive Therapy and Cognitive-Behavioral Therapy.

Cognitive Therapy (CT)

Aaron Beck developed CT, not to be confused with cognitive-behavioral therapy described below, to focus on the impact of the negative cognitive triad – that is, negative thoughts about the self, the future, and the world at large. He asserted that the link between thoughts and emotions was causal. CT aims to help patients identify maladaptive patterns in thinking, including defining and labeling the patterns. Essentially, patients discover their underlying core beliefs and schemas, which are thought to fuel depressive and anxious symptoms. According to Beck, schemas can be reduced to deep, underlying worries about being unlovable or helpless. CT aims to improve awareness of thought patterns, with the ultimate goal of transforming negative thought patterns into more accurate, adaptive thinking that will improve the quality of life of the patient and likely result in adaptive behavior change.

The Second Wave of Psychotherapy: Cognition as a Behavior

Traditionally, the theory of behaviorism defined “behavior” as that which can be seen and measured.20 Over time, the definition of what constitutes a behavior (or not) expanded to include cognition, or thinking, as a behavior, subjected to the same tenets of behaviorism’s learning theory. The inclusion of cognition as a behavior under the theory of behaviorism marks the second wave of behaviorism. Thus, cognitive theories can be used on their own as a stand-alone approach, separate from behaviorism, or used in conjunction with behaviorism.

Cognitive-Behavioral Therapy (CBT)

CBT is a structured, time-limited, present-focused approach to psychotherapy that helps patients engage in an active coping process aimed at changing maladaptive thoughts and behaviors that can serve to maintain and exacerbate the experience of chronic pain.

CBT protocols introduce cognitive concepts, such as automatic thinking and cognitive restructuring. Cognitive distortions, unconscious operations of the mind, are categories of automatic thinking. Negative cognitive distortions fall into four broad categories, including overgeneralization, mental filters, jumping to conclusions, and emotional reasoning.

Cognitive restructuring is a useful tool for understanding and turning around negative thinking. Cognitive restructuring requires an observation of distorted thought patterns, challenging distorted thought, and re-scripting the distorted thinking that lies behind them. In engaging in this active process, the patient learns to approach situations in a positive frame of mind.

CBT for pain is grounded in the notion that pain is a complex experience, influenced by its underlying pathophysiology and the individual’s cognitions, affect, and behavior.21 CBT for pain has three components:

  • a treatment rationale
  • coping skills training
  • the application and maintenance of learned coping skills.22

The goals of CBT are to reduce the impact pain has on the patient’s daily life; to learn skills for coping better with pain; to improve physical and emotional functioning; and to reduce pain intensity and consequently the reliance on pain medication.

Rational Emotive Behavioral Therapy (REBT)

Bridging the gap between CT and behavioral therapy is a type of CBT called REBT, developed by Albert Ellis. REBT has been used to treat rage, anxiety, frustrations, social phobia, shyness, and sexual dysfunctions. REBT brings awareness to automatic thought patterns in order to achieve a more desired, adaptive emotional outcome. REBT is based on the notion that people are capable of rational and irrational thought, and it is the capacity for irrational thought that causes distress. For example, an irrational thought may be, “If I experience any pain, it is terrible and I am unable to live a happy, fulfilling life.”

REBT aims to modify irrational thoughts and uses the A-B-C model as its predominant assessment and intervention tool. The A-B-C model purports that interpretations of the environment (or activating event-A) affect cognitions (or the beliefs about the event-B), which in turn drive our emotions and bodily sensations (or consequences-C).

Cognitive Processing Therapy (CPT)

CPT is a time-limited, cognitive-based treatment approach developed to treat trauma symptoms. When an individual suffers from trauma, they may find themselves thinking very differently about themselves and their environment, particularly in terms of safety, trust, control, esteem, and intimacy. These thoughts can lead to negative emotions, such as fear, anxiety, guilt, and anger, and can halt recovery.  CPT focuses on teaching a set of skills that will challenge these negative thoughts and gain control over the impact the thoughts have on the patient’s life.

Many individuals with chronic pain have a history of trauma. For patients who suffer from both trauma and chronic pain, pain sensations can trigger trauma symptoms and vice-versa. Treatment for trauma symptoms has been found to reduce pain and can help the patient better manage their pain levels and symptom flare-ups.

Target Patients: Research on cognitive approaches demonstrate an increase in reported self-efficacy and a decrease in pain catastrophizing in samples of chronic pain patients.23,24 Past research has shown CBT to be highly efficacious in the treatment of fibromyalgia,25 headaches,26 low back pain,27 osteoarthritic knee pain,28 and rheumatoid arthritis.29 Patients also appear to benefit from receiving an integrated treatment with components of CPT and CBT for pain and trauma symptoms.30

Integration of the Third Wave: Mindfulness and Acceptance

CBT has historically enjoyed the spotlight in the psychotherapeutic treatment of pain. More recently it has been used as a foundation to inform new approaches. Instead of aiming to modify maladaptive thought patterns, newer cognitive-informed approaches aim to increase awareness of thought patterns without judgment or attachment to them using mindful awareness.

Mindful awareness results in an unlinking of thought and emotion, which results in thoughts being present without an automatic emotional reaction. Approaches that stress acceptance of cognitive behaviors with curiosity rather than judgement are referenced as the third wave of behaviorism. Third wave approaches have been investigated for their impact on chronic pain patients. They include Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness Based Cognitive Therapy (MBCT).

Acceptance and Commitment Therapy (ACT)

ACT is a form of clinical behavior analysis that uses acceptance and mindfulness strategies mixed with commitment and behavior-change strategies. The primary goal of ACT is to increase psychological flexibility. ACT is informed by functional conceptualism and relational frame theory. Relational frame theory asserts that learning is contextualized, relational, and bidirectional.

ACT is highly experiential and its efficacy has been found to vary as a function of patient commitment and participation in treatment. The experiential elements of ACT challenge patients to learn and practice new and more flexible ways of responding to pain. The goal of ACT is to shift patients’ primary focus from reducing or eliminating pain to a focus on fully engaging in life, while accompanied by the pain.

ACT applies six core treatment processes:

  1. willingness to accept
  2. contact with the present moment
  3. observing the self
  4. cognitive diffusion
  5. values
  6. committed action.

These processes are achieved through different experiential exercises that create psychological flexibility.31 ACT’s underlying theoretical influences include Skinner’s Theory of Radical Behaviorism, which focuses on the reciprocal nature of behavior and the environment.

Target Patients: Past research has shown that ACT for chronic pain interventions decrease pain intensity,32 functional disability,33 psychological distress,34 and have shown improvements in pain interference35 among individuals with chronic pain.

Dialectical Behavior Therapy (DBT)

Informed by attachment theory, DBT was developed by Marsha Linehan in the late 1980s. It was developed to treat those who met criteria for borderline personality disorder, specifically suicidal thoughts, intentions, and gestures, which are symptoms that often accompany these patients. DBT is structured to help clients develop insight and skills to manage their thoughts, emotions, and behaviors.

Four modules make up DBT, including mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. The mindfulness module aims to cultivate a nonjudgmental awareness of both internal and external stimuli and seeks to replace judgment with curiosity. Once a foundation of mindfulness has been developed, a focus on skill acquisition begins across the remaining three modules, which is needed for the development of healthy interpersonal relationships.36

Target Patients: While DBT offers a theoretically feasible effective psychotherapeutic approach for pain management, there is very little research on the effectiveness of DBT with chronic pain patients.37 One study showed improvements in pain intensity, catastrophizing, fear, depression, sleep, and acceptance of pain as a result of DBT.38 While DBT shows promise, more research is needed on the effectiveness of DBT on chronic pain patients, specifically those who report high interpersonal distress and less treatment gains with traditional CBT.39

Mindfulness-based Cognitive Therapy (MBCT)

The development of MBCT was informed from both CBT approaches and mindfulness approaches, specifically mindfulness-based stress reduction (MBSR) developed by Kabat-Zinn, to treat treatment-resistant chronic pain. MBSR uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful. Like MBSR, MBCT is a manualized treatment, but was intended to be used to treat depression and found to be effective with pain management. It aims to increase body awareness and acceptance of sensory experiences.40

Target Patients: MBCT performs similarly to psychoeducation for pain interference, acceptance, and catastrophizing.41 MBCT performed better than treatment as usual in patients’ ability to self-regulate and tolerate uncomfortable bodily sensations.42 MBCT may also be effective in individuals with severe headache43 and in persons who accept their pain.44



Continuing to focus conversations around finding a miracle cure for pain management serves as a barrier to the effectiveness of psychological approaches for chronic pain patients. Consequently, healthcare providers should take time to assess patients’ attitudes and beliefs about pain. The gold standard practice has been to change maladaptive thoughts and behaviors that can serve to maintain and exacerbate the experience of chronic pain using CBT.

However, third-wave approaches instead aim for acceptance of thought without judgment. Further, it appears that a willingness to accept one’s pain condition is an important prerequisite for the effectiveness for most cognitive psychotherapeutic approaches. If patients are willing and motivated, approaches that integrate cognitive strategies and mindful awareness should be made available as they offer patients an alternative relationship with their thoughts and ultimately a different relationship with their pain experiences.  


Disclaimer: The views expressed in this article are those of the author and do not represent the views of the Department of Veterans Affairs or any other governmental agency.

Last updated on: August 3, 2020
Continue Reading:
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning
close X