A Magical Cure for Pain?
No – it’s just Cognitive Behavioral Therapy.
Posted Nov 28, 2020
When I first met Sam*, age 16, he’d been bedridden for 4 years. He had chronic migraine, fibromyalgia, and amplified pain. He was pale, with long, unwashed hair, and rocked himself back and forth from the pain. He’d seen 14 physicians and been on 40 medications. He’d missed so much school that he was at a 7th grade education level. He had no friends, no life, and no hope.
When nothing else helped, Sam was referred to me for Cognitive Behavioral Therapy (CBT). Despite the fact that CBT is an evidence-based treatment for chronic pain and illness rooted in science and research (Ehde et al 2014; Skelly et al 2018; Williams et al 2012), many people have never heard of it. Moreover, a referral to a psychologist often suggests to patients that their doctors think they’re “crazy,” that the pain is “all in their heads,” or that they’re faking. Between the stigma and lack of awareness, pain psychologists are the last stop on the pain train – if patients ever get to us at all.
Luckily, Sam was willing to try. His CBT program began with essential information about pain. He learned the connection between thoughts, emotions, and sensations; basic pain neuroscience; and how the cycle of isolation and inactivity “sensitizes” brain and body, making pain feel worse. We developed a pacing plan, gradually introducing his body to increasing amounts of movement, activity, and stimulation. He started walking around the block, then jogging. Over the next few months, he reached out to old friends, changed his diet and sleep habits, got a tutor, and caught up in school. The cycle was reinforcing: the more he did, the more he could do – and the better he felt.
Little by little, his symptoms changed. As his mood improved and anxiety subsided, his pain starting decreasing, too. After 4 years of isolation and inactivity, each small step felt huge, and proved to his brain and body that progress was possible. Slowly, slowly, Sam got back to life.
I went to Sam’s high school graduation last year. He got onstage – this teen once paralyzed by misery and pain – and told the audience that, if you’d told him 4 years ago that he’d be graduating high school, he’d never have believed you. We all cheered. His parents cried.
Was it magic…?
It was CBT.
The Science of Pain
How can a “psychological” therapy treat a “physical” problem? The answer is both simple and complex. While we think of pain as a purely biomedical problem to be treated exclusively with pills and procedures, science reveals that pain is actually biopsychosocial: produced and reduced by a combination of biological, psychological, and social factors. Furthermore, pain relies upon input from the limbic system – the brain’s emotion center. This means that pain is both physical AND emotional 100% of the time. Neuroscience confirms that negative thoughts and emotions amplify pain, while positive thoughts and emotions turn pain volume down (Flor, 2014; Martucci & Mackey, 2018). To effectively treat chronic pain, we must therefore change the brain.
CBT has the power to alter both brain and body, neuroscience and biology, calming the pain system and increasing functioning (Davidson et al, 2003; Petersen et al, 2014). When done right, CBT includes a combination of pain education; pain management strategies, including biobehavioral techniques that directly impact physiology like biofeedback, relaxation strategies, and mindfulness; coping skills; behavioral activation, movement, and pacing; cognitive strategies; stress and mood management; and lifestyle changes focused on sleep hygiene, social engagement, and nutrition. Research suggests CBT is efficacious, cost-effective, and can have a lasting impact without the side effects of medications (Majeed & Sudak, 2017). It’s been shown to significantly reduce pain intensity and disability, while improving functionality and quality of life (Adronis et al, 2017; Murphy et al 2020; Pigeon et al 2012). It’s also associated with reduced need for pain medications, including opioids (Garland et al, 2019), and can even be conducted virtually – critical during COVID-19.
CBT for Pain
As a pain psychologist, I see the effectiveness of CBT every day as my patients get out of bed and back to life. Indeed, CBT for pain is so promising that policymakers at the highest levels – the CDC (Dowell et al, 2016), National Academy of Medicine (NAM, 2017), FDA (2017), Pain Task Force (Tick et al, 2017), and medicine’s Joint Commission (2018) – all clamor for its use. Top pain management programs, including those at UCSF, Stanford, and Dartmouth-Hitchcock, already incorporate CBT into their pain clinics.
However, detractors remain, and understandably so. Measuring the impact of CBT is complex, and the research is not without flaws. Issues include:
1. Definition of CBT. There’s no standardized, operational definition of “CBT for pain.” Read 10 journal articles, and you'll get 10 different definitions. Each study utilizes a different combination and number of strategies, so we’re never comparing apples to apples.
2. Treatment length. Across studies, treatment is administered for different lengths of time. Some studies measure outcomes at 6 weeks, others at 12 weeks, etc. As with medication, dose matters.
3. Treatment delivery. Across studies, “CBT” is delivered by providers of different backgrounds and training: some are graduate students, others are social workers, and still others are expert pain psychologists. This is problematic, as research indicates that outcomes vary depending upon the treatment provider. Who delivers the treatment matters.
4. Treatment recipients. Studies measure the impact of “CBT” on a variety of patient samples with different types of pain and etiologies. Additionally, many studies fail to control for confounding variables like trauma history and adverse childhood experiences (ACES; Felitti et al, 1998). Who receives the treatment matters.
Interestingly, CBT has strong evidence of effectiveness even when the packaging is removed and its broken down into its component parts. Pain education, behavioral activation, exercise, relaxation skills, mindfulness techniques, cognitive strategies, biofeedback, guided imagery, sleep hygiene, and other strategies are independently supported for treating chronic pain.
Take Home Notes
In summary, here’s what we know:
- While there's no magic cure for pain, CBT is an effective, evidence-based treatment for various types of chronic pain and illness, from migraine to low back pain to fibromyalgia. It can be delivered as a package or in component parts, in person or virtually.
- Compared to medications for pain, CBT is more effective, safer, longer-acting, and has fewer (if any!) side effects.
- A concrete, operational definition of “CBT for pain” is needed so that we can more accurately assess efficacy.
- Due to stigma, poor insurance reimbursement, and lack of trained professionals, CBT isn’t sufficiently or widely utilized.
- No matter how long you’ve been in pain, there is hope. CBT-based resources are being mobilized. See the references section for additional reading and resources.
*This article is adapted from The Pain Management Workbook, a CBT-based book for patients living with pain and the providers who treat them. Patient names & identifying info have been changed to protect identity.
Zoffness, R. (2020). The Pain Management Workbook. New Harbinger Publications.
Andronis L, Kinghorn P, Qiao S, Whitehurst DG, Durrell S, McLeod H. Cost-effectiveness of noninvasive and non-pharmacological interventions for low back pain: a systematic literature review. Appl Health Econ Health Policy. 2017;15(2):173-201. 212.
Dowell D, Haegerich TM, Chou R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep;65(No. RR-1):1–49.
Ehde DM, Dillworth TM, Turner JA. (2014) Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol., 69:22–29.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.
Majeed, M. H., & Sudak, D. M. (2017). Cognitive behavioral therapy for chronic Pain—One therapeutic approach for the opioid epidemic. Journal of Psychiatric Practice, 23(6), 409-414. https://www.ncsbn.org/0122017_Cognitive_Behavioral_Therapy.pdf
Murphy, J. L., Cordova, M. J., & Dedert, E. A. (2020). Cognitive behavioral therapy for chronic pain in veterans: Evidence for clinical effectiveness in a model program. Psychological Services. Advance online publication.
National Academy of Medicine (NAM). 2017. First do no harm: Marshaling clinician leadership to counter the opioid epidemic. Washington, DC: National Academy of Medicine.
Pigeon WR, Moynihan J, Matteson-Rusby S, et al. (2012) Comparative effectiveness of CBT interventions for co-morbid chronic pain & insomnia: a pilot study. Behav Res Ther. 50(11):685-689.
Skelly AC, Chou R, Dettori JR, et al. (2018). Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality (US); Report No.: 18-EHC013-EF. PMID: 30179389.
Sturgeon, J. A. (2014). Psychological therapies for the management of chronic pain. Psychology research and behavior management. (7): 115–124.
The Joint Commission. Joint Commission enhances pain assessment and management requirements for accredited hospitals. 2017; https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_ and_Management_Requirements_for_Accredited_Hospitals1.PDF
Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon, RL, Wayne PM, Zador, V. (2017). The Pain Task Force of the Academic Consortium for Integrative Medicine and Health. Evidence-based Nonpharmacologic Strategies for Comprehensive Pain Care. A Consortium Pain Task Force White Paper. www.nonpharmpaincare.org
U.S. Food and Drug Administration (FDA, 2017). FDA education blueprint for health care providers involved in the management or support of patients with pain. 2017; https://www.fda.gov/downloads/Drugs/NewsEvents/UCM557071.pdf.
Williams A, Eccleston C, Morley S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev., 11:CD007407.