Cognitive behavioral therapy (CBT)

The bottom line

Chronic pain often brings along its party-pooper friend, chronic depression. The relationship between the two is complex. Talk therapy is often used for depression, but it could also be quite useful for pain, although the evidence is mixed on this.

When should you consider trying Cognitive Behavioral Therapy?

Unfortunately, chronic pain doesn’t always respond to “first-line” treatments like medication and physical therapy. Even when these treatments do work, patients are often left with residual pain and functional impairment. What then? Give up. Yes, that sounds like a good strategy. No no, just kidding, don’t! There are tons of options out there.

One option is cognitive-behavioral therapy (CBT) focused on pain management. CBT is a kind of psychotherapy used for many different conditions, including depression, obsessive-compulsive disorder, and panic disorder. Broadly speaking, CBT focuses on how thoughts, emotions, and behaviors interact and affect one another, and how altering one of these components can result in changes in the others. CBT for chronic pain is based on the assumption that emotional and behavioral factors can dramatically influence the way a person experiences pain. Indeed, why not talk to someone who is a pro at talking about the mental aspect of health issues?

How is CBT different than just talking to your shrink?

It’s important to know that CBT differs from traditional types of psychotherapy. It tends to be more structured, with an agenda for each session and homework between sessions. It’s present-focused, meaning that there’s not much exploration of childhood or the origin of a person’s symptoms. The client and therapist identify specific goals for treatment and periodically assess progress toward those goals. So there’s no lying on a couch and free associating in CBT. Therapy is more likely to last a few months than a few years, which makes CBT easier to study in clinical trials. Note that what I’ve described here is CBT in its purest form.

The way you think affects your pain perception

According to the cognitive-behavioral model of pain, the way people think about their pain may affect its severity and the degree of functional impairment it causes. Some people, for example, become so fearful of their pain, or of reinjuring themselves, that they start to avoid physical activity. Fear of pain is HUGE in influencing how your brain conditions itself to deal with chronic pain. Unfortunately, this strategy tends to increase people’s fear of pain, not to mention limit their pursuit of meaningful activities. Countless people become scared of doing physical therapy, getting out of bed, and other things that may be very helpful in the long run.

Therapy is a structured way of changing your mindset

There are a variety of CBT protocols for the management of chronic pain, but they tend to have a few elements in common. Nearly all of them involve identifying and challenging maladaptive thoughts related to chronic pain (e.g., “I can’t do anything when my pain is really bad”). Presumably, maladaptive thoughts about one’s pain decrease one’s ability to cope with it and, perhaps, make it feel more intense. The therapist’s goal isn’t to convince the client that pain isn’t a big deal, but to assist the client in perceiving his or pain as less overwhelming. Other components of treatment may include training in problem-solving, muscle relaxation, and attention diversion (i.e., purposeful distraction).

CBT for chronic pain has been tested and refined in dozens of trials over the last several decades. So there must be a wealth of evidence that it works, right? Well . . .

The evidence is conflicting

According to the Cochrane Collaboration’s 2009 systematic review and meta-analysis of psychological treatments for non-headache pain, CBT has (1) a small to moderate effect on pain when compared to a wait-list control group or treatment as usual, (2) a small effect on disability (i.e., it reduces functional impairment a little) when compared with an active treatment and (3) no effect on mood immediately post-treatment when compared with an active treatment, wait-list control, or treatment as usual. Overall, the evidence for CBT for chronic pain is weak.

These results are somewhat surprising given that earlier reviews reached more favorable conclusions about CBT for chronic pain.

So whom do we believe?

At this point, the Cochrane review is the most up-to-date and rigorous one available. Nevertheless, it doesn’t include trials of CBT for chronic pain published over the past few years. The evidence base is always changing and treatments are always being refined. The most recent forms of CBT for chronic pain incorporate training in mindfulness meditation and emphasize the importance of engaging in value-based actions while accepting the presence of pain., a registry of trials conducted around the world, indicates that numerous trials of CBT for chronic pain are ongoing. Although the evidence base for CBT for chronic pain isn’t very impressive right now, that could change in a few years.

It’s tough to tell whether CBT will work for you

Given the weak evidence base for CBT for chronic pain, would it be a waste of time to seek it out? I’m not so sure. The psychiatry/psychology literature isn’t particularly good at determining what works for whom. In other words, in any given trial, there are some people who benefit from the treatment (responders) and some who don’t (nonresponders). It would be really useful to know what differentiates responders from nonresponders. Is it something about their personalities? The type of pain syndrome they have? Is it some other variable that researchers haven’t measured? Unfortunately, we don’t know the answers to these questions. There is some evidence that higher levels of depression and rumination predict a poor response to CBT for chronic pain. Given the state of the literature, it’s hard to say much else about what factors moderate treatment response. So you may benefit from CBT for chronic pain, but, as with many other kinds of treatment, there’s no good way to predict if you’ll be a responder.

It may be worth considering CBT if you suffer from anxiety and/or depression in addition to your chronic pain. Although the Cochrane review discussed earlier found that CBT for chronic pain wasn’t associated with mood improvements, there is ample evidence that CBT focused on symptoms of depression and anxiety is quite helpful.

Next steps: Consider making an appointment

So let’s say you want to find a cognitive-behavioral therapist. Where do you start? You can solicit recommendations from your medical doctors. You could also search for therapists near you on the Association for Behavioral and Cognitive Therapies site. Unless you’re willing to pay out of pocket, it’s important to determine which therapists (and how many sessions) are covered by your insurance. Once you start seeing a therapist, don’t be afraid to switch if you can’t establish a good working relationship. The therapeutic alliance—the hard-to-define collaborative and emotional bond between client and therapist—may be a better predictor of treatment success than anything else.