Access to the PPM Journal and newsletters is FREE for clinicians.
11 Articles in Volume 16, Issue #7
A Perspective on Tapentadol Therapy
Acupuncture to Treat Brachial Plexopathy and CRPS
Behavioral Medicine: How to Incorporate CBT Into Pain Management
EpiPens and Opioids: Common Ground
Fibromyalgia and Coexisting Chronic Pain Syndromes
Life-Saving Naloxone: Review of Currently Approved Products
Medical Foods Hold Promise In Chronic Pain Patients
Moving Beyond Pain Scales: Building Better Assessment Tools for Today’s Pain Practitioner
Moving Toward an (Almost) Opioid-Free Emergency Department
No Perfect Medicine—What You Need to Know About NSAIDs and Opioids
Prescribing Opioids: How New Policies Are Affecting Medical Specialties

Behavioral Medicine: How to Incorporate CBT Into Pain Management

Cognitive-behavioral interventions improve psychological and physical functioning. They help patients let go of the struggle against pain and move toward achieving their most valued life goals. Medical management is also more effective if depression, anxiety, and other mental health symptoms are addressed. —Mark Jensen, PhD

There is a great deal of evidence to support the effectiveness of various cognitive-behavioral interventions for reducing pain intensity and improving a patient’s coping skills. Behavioral medicine approaches aim to modify the overall pain experience, help restore functioning, and improve the quality of life of patients who suffer from chronic pain. The most common interventions include acceptance and commitment therapy (ACT) and traditional cognitive-behavioral therapy (CBT).

The literature has shown that ACT compares favorably with traditional CBT in the treatment of chronic pain among different populations, including cancer patients,1 individuals in a university-based pain management outpatient clinic,2 Australian patients at a pain management unit,3 and community samples including a small representation of veterans.4 Research has also found that for chronic pain, both ACT and CBT interventions decrease pain intensity,2,5-8 disability,2,9-11 and pain interference.4,5,8,12

In addition, both ACT and CBT interventions have been found to increase readiness to adopt a self-management approach13,14 and create changes in the way a person copes with chronic pain.15,16 However, considerable variability in outcomes exists between these interventions: ACT and CBT do not have uniform effects and are not effective for all patients.3,4,17 For example, ACT and traditional CBT tend to overlap in terms of behavioral techniques and strategies, but there are specific theoretical differences that exist with regard to the role of cognitions and emotional regulation strategies.

Acceptance & Commitment Therapy

Chronic pain is a complex biopsychosocial condition, requiring a multimodal approach to management. The first wave of behavioral medicine interventions, based on behavior theory, commenced in the 1920s, while the second wave, based on cognitive-behavioral theory, emerged in the 1970s. ACT is one of the more actively researched approaches amongst the third wave of developing psychotherapies.18

ACT is distinct from other mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and dialectical behavior therapy (DBT). For example, MBSR uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful. MBCT uses traditional CBT methods and adds in mindfulness meditation. Mindfulness is a core exercise used in DBT, which combines standard cognitive behavioral techniques for emotion regulation with concepts of distress tolerance derived from Buddhist meditative practice. What sets ACT apart is that it is a form of clinical behavior analysis that uses acceptance and mindfulness strategies, mixed with commitment and behavior-change strategies, to increase psychological flexibility.

ACT is a style of therapy with a lot of flexibility, and the therapeutic process is more experiential than didactic. Therefore, efficacy will depend largely on the patient’s level of commitment and participation in treatment. The experiential elements challenge patients to learn and practice new and more flexible ways of responding to pain. The basic idea of ACT is for patients to shift their primary focus from reducing or eliminating pain to fully engaging in their lives. ACT is about changing how patients relate with their internal experiences; it is about living better.

A primary goal of treatment is for the patient to suffer less through becoming actively involved in what they really care about and what matters most in their life, despite having and experiencing pain. ACT treatment is difficult, as there are no simple solutions to chronic pain. Patients might feel a range of emotions (sad, angry, anxious, hopeless, and/or uncomfortable) during the intervention, but this response is natural and perfectly normal. The role of the therapist is to help patients accept whatever discomfort exists, both physical and emotional, while continuing to live their lives according to their values. Doing so can help patients make meaningful changes in their lives and reduce suffering.

There are a number of established protocols that have been published for ACT for chronic pain.19-20 One protocol proposed a 4-session intervention, which combined individual and group treatments, and thus established the feasibility of using ACT to treat people with chronic pain.19 This protocol was one of the first to address case formulation and clinical techniques in a practical way with a chronic pain population. The second protocol is an 8-session intervention that presents topics typical of a traditional CBT protocol (activity pacing, goal setting, homework, etc).20 There are also separate self-help books that provide step-by-step instructions. The self-help books serve as an introduction to the therapy rather than a protocol.21

ACT applies 6 core treatment processes (willingness to accept, contact with the present moment, observing the self, cognitive defusion, values, and committed action) through different experiential exercises to create psychological flexibility.22 The model is best illustrated using a hexaflex (Figure 1). A simplified model may suggest the intervention helps patients to become more open, present, and take action.

Being Open

Patients learn to become more “open” to their experience of pain using 2 principles: willingness to accept (versus avoidance or escape) and cognitive defusion (versus fusion with thoughts). The principle of willingness to accept describes the process of allowing internal experiences (thoughts, feelings, body sensations, and memories) regarding pain to come and go without struggling with or becoming fused with them. When learning about cognitive defusion, patients begin to create distance from thoughts, images, emotions, and memories and perceive them as what they are. This can work to help the patient create distance from these experiences and realize that they are not identified by their thoughts. This way the patient can work to respond to these experiences through evaluating their workability given their values, rather than accepting or “buying into” them in a literal way.

Being Present

Patients learn to become more “present” with their experience of pain using 2 other principles: contact with the present moment (versus living in the past or future) and observing the self (versus dominance of the conceptual self). The principle of making contact with the present moment describes how patients become more aware of and experience the here and now. Mindfulness is essential to this process! Mindfulnes is neither a special mystical state, nor a form of relaxation. Mindfulness is an exercise in just noticing, or awareness. The purpose is not to change or judge, but rather to be fully in the present moment, noticing when the mind wanders and bringing it back. It involves being able to operate from a different and separated point of view.

The aim of mindfulness is to increase awareness of one’s body functions, feelings, and the content of thoughts. Each therapy session begins with a mindfulness exercise. Observing the self involves patients accessing a transcendent sense of self, a continuity of consciousness that is always changing. In other words, patients learn to contact their thoughts and feelings about pain from the perspective of a separate observer.

Taking Action

Patients also learn to “take action” despite their experience of pain using these principles: valued directions (versus lack of values clarity) and committed action (versus lack of consistent action). The principle of valued directions describes the process of discovering what is most important to one’s true self, whether it be personal growth, leisure, citizenship, social relationships, health, work/education, spirituality, family, parenting, and/or intimate relationships.  

Making a committed action involves the patient setting goals according to their values and carrying them out responsibly. Patients are asked to state and write down commitments in the form of specific, measurable, achievable, realistic, and tangible steps that they are now willing to take, along with what activities they are willing to do.

At the end of the intervention, patients are taught how to maintain their progress by continuing to:

  • Practice mindfulness and acceptance exercises
  • Set short-term goals each week
  • Monitor their progress

Patients are also prepared for relapse and setbacks. When they have a setback, as when they fail to live up to or keep their commitments, they are trained to recommit to their action plan. The patient then gets back on track by noticing the setback and bringing their awareness back to their valued directions. ACT has been shown to have modest support, but CBT has strong, long-standing research to support the treatment of chronic, non-cancer pain, according to the American Psychological Association.23

Cognitive-Behavioral Therapy

CBT has been shown to be highly efficacious in the treatment of a number of chronic pain conditions, including fibromyalgia,10 headaches,24 low back pain,11,25 osteoarthritis,26 and rheumatoid arthritis.27 Furthermore, meta-analytic comparisons have substantiated these findings and have proven CBT to be a skill of utmost importance in pain management.28,29 CBT for pain is based upon the cognitive-behavioral model of pain.30

The cognitive-behavioral model is grounded on the notion that pain is a complex experience that is influenced by its underlying pathophysiology and the individual’s cognitions, affect, and behavior.31 In other words, “as I think, so I feel (and do)!” CBT for pain has three components: a treatment rationale, coping skills training, and the application and maintenance of learned coping skills.32 The goals of CBT are to:

  • Reduce the impact pain has on the patient’s daily life
  • Learn skills for better coping with pain
  • Improve physical and emotional functioning
  • Reduce pain and the reliance on pain medication

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. There are a number of established protocols that have been published for CBT for pain.33 One particular protocol, “Treatments That Work,” reviews pain education topics, such as chronic pain syndrome and theories of pain.

In CBT, chronic pain syndrome is defined as a constellation of symptoms (mood, relationships, social activities, work/education, play/leisure, etc) that usually do not respond to the biomedical model of care. This condition is best managed with an interdisciplinary approach requiring good integration and knowledge of multiple organ systems.34 Since the 17th century, there have been several different theories of pain perception, from the intensity theory to the gate-control theory of pain. Intensity theory proposed that a stimulus sensation and a reflex response operate within identical neural circuitry, but are differentiated by way of intensity. A stimulus, like an itch, would activate neurons at a low level, while a reflex response, such as soothing from scratching, would generate neurons at higher levels. Evidence against intensity theory has since developed and ultimately led to the current philosophy.

In 1965, the gate control theory proposed that there is a “gate,” or control system, in the dorsal horn of the spinal cord through which all information regarding pain carried by the nerves of the body must pass before reaching the brain. When the gate is “open,” the nerves can carry signals from the body to the brain, where pain is perceived. Chronic pain is believed to persistently activate this transmission to the dorsal horn and induce it to “wind up.” Over time, this phenomenon induces pathological changes that lower the threshold for pain signals to be transmitted. When the gate is “closed,” the nerves signals are restricted access to the brain. The goal of CBT is to help “close” the gate.

CBT protocols also introduce cognitive concepts, such as automatic thinking and cognitive restructuring. Automatic thoughts spontaneously come to mind when a particular situation occurs. Cognitive distortions, unconscious operations of the mind, are categories of automatic thinking. People do not choose their cognitive distortions, but act on them without even being aware of their negative implications. Negative thinking opens the “gate” and causes an increase in pain perception.

The first step to changing cognitive distortions is to recognize them. Negative cognitive distortions fall into 4 broad categories, including overgeneralization (taking isolated cases and using them to make wide generalizations), mental filters (focusing on negative aspects of an event while ignoring positive aspects), jumping to conclusions (making decisions from little evidence), and emotional reasoning (making decisions based on personal feeling rather than evidence).

Cognitive restructuring is a useful tool for understanding and turning around negative thinking. It involves observing negative thoughts closely, challenging them, and re-scripting the negative thinking that lies behind them. By engaging in this active process, the patient learns to approach situations in a positive frame of mind. The key idea behind cognitive restructuring is the A-B-C model, which purports that interpretations of the environment (or activating event-A) affects cognitions (or beliefs about the event-B), which in turn drives our emotions and bodily sensations (or consequences-C).

Furthermore, CBT protocols introduce behavioral strategies, such as relaxation techniques (any method, process, procedure, or activity that helps a person to relax), time-based activity pacing, and pleasant activity scheduling. There are several types of relaxation techniques employed in CBT, including diaphragmatic breathing, progressive muscle relaxation (PMR), and visual imagery. Diaphragmatic breathing is the act of breathing deep into the lungs by flexing the diaphragm, rather than breathing shallowly by flexing the rib cage or raising the shoulders. This deep breathing is marked by expansion of the abdomen rather than the chest when breathing. It is generally considered a healthier and fuller way to ingest oxygen, the source of life, and is often used as a therapy for pain management.

PMR is a technique for reducing muscle tension by alternately tensing and relaxing the muscles. PMR entails physical and mental components. The physical component involves the tensing and relaxing of different muscle groups of the body. With the eyes closed, and in a sequential pattern, tension in a given muscle group is purposefully held for approximately 10 seconds and then released for 20 seconds before continuing with the next muscle group—usually starting with the toes and feet and then going up the body. The mental component focuses on the difference between the feelings of tension and relaxation. Because the eyes are closed, one’s concentration is focused on the sensation of tension and relaxation. In visual imagery, the therapist guides the patient through a process of visualization to create images that serve as messages from the unconscious to consciousness. In order for these images to be effective, the visual imagery exercise should be practiced at least once daily.

Another behavioral strategy that is taught is time-based pacing, or an activity-rest cycle. There are 4 steps to time-based pacing: list some things the patient tends to overdo, limit the amount of time for the activity, stop the activity and rest when the time is completed (not the task), and repeat the cycle until the task is complete.

Pleasant activity scheduling is another way to increase positive emotions and to “close” the gate. There are 4 steps to pleasant activity scheduling:

  • List activities that the patient thinks might be pleasurable
  • Rate each activity according to current ability
  • Schedule the activities during the next week
  • Review progress, then attempt again during the next month

At the end of the intervention, patients create a plan for how to use the skills learned when they have a pain flare-up. The plan involves the following steps: 1) prepare for a flare-up before it occurs; 2) confront the flare-up head-on (do not ignore it); 3) avoid pitfalls during critical moments (watch out for cognitive distortions); and 4) reflect upon which skills were successful and create a new plan for the next flare-up, because there will be another one in the future.

Last updated on: December 29, 2020
Continue Reading:
No Perfect Medicine—What You Need to Know About NSAIDs and Opioids

Join The Conversation

Register or Log-in to Join the Conversation
close X