The Cognitive-Behavioral Therapy Approach to Managing Chronic Pain

Pain is very complex and as might be expected there are many well-known treatment options that include medications, medical approaches, non-medical therapies, acupuncture, surgery, and (often thought to be lesser mind-body techniques) such as Cognitive Behavioral Therapy (CBT).  Mind-body practices are techniques that are designed to enhance the mind’s positive impact on the body.  Awareness of the mind-body connection is definitely not a new idea, but it often seems “weird” to many in the Western World where for centuries the mind and the body have traditionally been seen as distinct and separate entities.  Nonetheless, this view is very rapidly changing as researchers continue to scientifically prove the complex links between the mind and body and the ultimate power of the mind itself.  It is important to learn the benefits and risks of each possible treatment, including addiction before you settle on what is best for you.  Of course, it is always advisable to be under the care of a primary medical doctor in most cases.

As to medicines, there are a great many prescribed and over the counter (OTC) medications to treat a range of pains and your doctor should be involved with this approach.  Medicines can often have undesirable side effects and may not be appropriate for everyone.  Some, especially those in the narcotic range, can be highly addictive and have other dangers that could lead to death.  With medicines, there are always the issues of tolerance and dependence.  Often vitamins (nutritional supplements) and herbs are considered medicines and some are very beneficial, but use caution here as these should be seen as “supplements” to other often more effective approaches.

Then, there is chiropractic care for pain which has been shown to be helpful in treating neck and back pain as well as headaches.  You need to choose carefully when taking this approach as a bad practitioner can do irreparable damage.  In addition, research shows that some alternative therapies such as acupuncture work very well on many people.  In cases of severe pain from whatever source, there are still other approaches, which include but are not limited to: Nerve block injections (local anesthesia); trigger point injections; spinal cord stimulation; patient-controlled analgesia (PCA pump; TENS (Electrothermal Therapy); and bioelectric therapy.

In the past decade or so, there has been strong, accumulative evidence regarding the major benefits of the mind-body therapies, especially Cognitive Behavioral Therapy also known as CBT, which is a kind of talk psychotherapy used to treat depression, anxiety disorders, phobias, pain management, and other mental issues.  The basis for this type of treatment is the recognition of distorted, malfunctional thinking and learning to replace this thinking with more realistic, functional ideas.  CBT is notably a short-term, goal-oriented psychotherapy treatment that focuses on changing the patterns of thinking or behavior that underlie a person’s difficulties, and thereby change the way they feel.  Pain management by CBT is found to be very effective in both adults and children.  Children are typically hard to treat because it is very difficult to get an objective and accurate measurement or a good description of a child’s pain.  (www.webmd.com/mental-health/guide-to-psychiatry-and-counseling)

Mind-body practices include behavioral, psychological, social, spiritual, and expressive approaches such as Guided Imagery, Meditation, Prayer, Yoga, Biofeedback, and of course CBT.  In an article by Elizabeth Shimer Bowers called “Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach,” the CBT Approach to pain management is skillfully explored (www.webmd.com/pain-management/features/cognitive-behavioral).  Bowers notes that when “your body is aching and the pain feels unbearable the last thing you want to hear is, ‘it’s all in your head.’  For people with chronic pain, the discomfort is very real, and they know all too well they feel it in their bodies.”  Thus comes, Cognitive Behavioral Therapy (CBT), which, again, is a type of talk therapy that helps people to identify and develop skills instrumental in changing their negative thoughts and behaviors.  CBT posits that people will create their own experiences internally (including pain perception) and that by changing negative thoughts and behaviors, individuals can change their “awareness” of pain, which will help them develop better coping skills, even if the pain level is actually the same.  Sooo, pain is in your brain!

Elizabeth Shimer Bowers addresses the question, “What can CBT do for you?” and then she goes on to say that it helps provide pain relief in several ways which include: Changing the way people view pain by changing thoughts, emotions, and behaviors related to pain; it improves coping strategies; and it also puts the discomfort in a better context.  Dr. Joseph Hullett, MD, a Board Certified Psychiatrist and Senior Medical Director for OptumHealth Behavioral Solutions in Golden Valley, Minnesota, notes in his responses to WebMD, LLC that in the process of CBT, people “recognize that the pain interferes less with your quality of life, and therefore you can function better.”  Furthermore, he says, “CBT can change the physical response in the brain that makes pain worse.”  Since pain causes stress and stress affects pain control chemicals in the brain such as norepinephrine and serotonin, Dr. Hullett is quoted as saying, that CBT “reduces the arousal that impacts these chemicals.”  In other words, CBT can help make the body’s natural pain relief mechanisms much more powerful.

Bowers points out that CBT is often used with other pain management approaches in order to more effectively treat chronic pain.  According to Dr. Hullett, studies have found that CBT is most often one of the most effective approaches to pain control and that in control group studies, it is “almost always as least as good as or better than other treatments.  Plus, CBT has far fewer risks and side effects than medications or surgery.”

People often ask, “What does CBT actually do?” and the answer is basically to provide pain relief through the following, according to Hullett:

• Encourages a problem-solving attitude. Hullett says, “The worst thing about chronic pain is the sense of learned helplessness — ‘there is nothing I can do about this pain,’”.  He further notes, “If you take action against the pain (no matter what that action is), you will feel more in control and able to impact the situation.”
• Involves homework. “CBT always includes homework assignments,” Hullett says. “These may involve keeping track of the thoughts and feelings associated with your pain throughout the day in a journal, for example. Assignments are then reviewed in each session and used to plan new homework for the following week.”
• Fosters life skills.CBT is skills training.  According to Hullett, “It gives patients coping mechanisms they can use in everything they do.  You can use the tactics you learn for pain control to help with other problems you may encounter in the future, such as stress, depression, or anxiety.”
• Allows you to do it yourself.Hullett notes that unfortunately, good qualified cognitive behavioral therapists aren’t readily available everywhere.  He posits that a person can conduct CBT on their own as a method of pain control.  He says, “CBT is a cookbook approach.  It can easily be applied to self-help and computerized programs.”  Note, literature supports that self-help methods can be just as effective for pain management as one-on-one sessions.  However, whatever the choice, professional guidance is best.

Have chronic pain?  Yes?  Well then, to start, first speak with your doctor about various treatments for you.  Your physician may be able to refer you to a cognitive behavioral therapist that specializes in chronic pain management or at least be able to point you in the right direction.  You may also be able to find a competent therapist through your insurance company or from the Internet.  Note, your insurance company may or may not cover pain management treatment or may cover only partial treatment, and most require a psychiatric diagnosis – check with your carrier before beginning any services.

What to expect, easy – weekly group or individual session lasting 45 minutes to two hours for between eight and 24 sessions.  There may be refresher sessions to help keep your skills sharp.  Expect a thorough evaluation regarding your pain which should at minimum include an extensive history of your pain, your current management methods, and finally a treatment plan.  Importantly, there should also be a general psychological assessment specifically to identify any issues that may be making your pain worse and a diagnosis, if needed.

A crucial question is, “What is the best way to ensure that you have found a good CBT therapist for pain management?”  Hullett provides the following:

• Check for credentials. Be sure the professional is qualified and licensed and has training and certification in pain management.
• Conduct an interview.  Get information directly from the therapist and see how comfortable you feel talking with him or her.
• Choose someone you like.  Hullett notes that in studies, the number one determinant of positive outcome depends on whether or not the client likes their therapist.  Therefore, now matter how much you respect a therapist as a professional, if you don’t like them personally, find another one.

“How do I get the most from CBT pain management?”  Well, here is the nutshell version for getting the most from CBT pain management or from most anything else in life:

• Believe it will work. Believe in the power of your mind and body.
• Actively participate. You get out what you put in; do the work, get the results.
• Complete the program. Do everything asked of you to your best ability – all of it.
• Practice the new skills. Practice, practice, practice the skills, even if not in pain.
• Keep an open mind. Your mind is very, very powerful, use it.

Bottom Line: CBT works well for pain management in conjunction with other treatments and sometimes alone.  Oh, and here is the most helpful indicator of the need for pain management that I have found to date:

This article was written by Elizabeth Ribicki, a VCC Therapist who helps clients manage chronic pain.