Cognitive Behavioral Therapy for Chronic Pain (CBT-CP)
Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) is a goal-oriented therapeutic approach that helps people change their thoughts, emotions, and behaviors in order to decrease their pain and distress, and ultimately improve their quality of life.
Physical pain influences the mind, and the mind influences physical pain. CBT-CP targets the connection between the two, which provides the foundation for individuals to shift how they relate to their pain. CBT-CP encompasses a suite of tools, including pain management, pain education, behavior changes, relaxation, coping skills, and lifestyle adjustments with food, movement, and nutrition. A tailored combination of these tools can help decrease the experience of pain and the toll it can take on people’s well-being, restore their sense of control, and, empower them to strive toward other goals.
CBT-CP is a variant of cognitive behavioral therapy (CBT), which was developed by Aaron Beck in the 1970s to treat depression. CBT holds that an individual’s thoughts can shape their emotions, moods, and behaviors, and that correcting maladaptive thought patterns can reduce distressing symptoms and help people flourish. CBT has since been used to treat many challenges and disorders, and it’s sometimes tailored to specific conditions, as in the case of CBT-CP.
In the 1960s and 70s, the biological understanding of pain began to deepen, eventually establishing that psychological and social factors—such as rumination, catastrophizing, fear-driven avoidance, activity level, and altered relationships, among others—could affect the physical experience of pain, and that talk therapy and CBT could benefit pain patients. These insights led CBT to be tailored to treat chronic pain in the 1980s and 90s. For example, a 2007 meta-analysis of 22 trials for chronic back pain found that psychological interventions like CBT had positive effects on pain, on pain-related interference with activities, on health-related quality of life, and on depression.
When It’s Used
CBT-CP is used to treat chronic pain, which is pain that has persisted for longer than three months. (Pain that is momentary or short-term is called acute pain.)
CBT-CP can treat individuals grappling with chronic pain from any source. Common conditions that CBT-CP addresses include back pain, headaches, arthritis, orofacial pain, and fibromyalgia, among others.
Individuals may employ CBT-CP when pain disrupts their quality of life—when they need to reduce their pain but also improve their coping skills and their life even in the presence of pain.
It’s often used in combination with other treatments, including medication and other therapies.
What to Expect
Treatment with CBT-CP involves weekly hour-long sessions with a therapist for between 6 and 12 weeks on average. However, the length of treatment may be tailored to an individual’s specific symptoms, trajectory, and treatment goals. Goals may include living a more balanced life, spending more time doing things they enjoy, avoiding flare-ups, and feeling more confident in managing their pain.
During a session, the therapist may guide the client to report on their level of pain and related behaviors over the past week, explore their thought processes, develop coping skills, and plan incremental steps to progress toward their goals.
The person may also be assigned exercises to complete between sessions, such as tracking their thought patterns, practicing their relaxation skills, or incorporating movement when appropriate.
CBT-CP typically doesn’t eliminate one’s pain or underlying medical condition altogether, but it reduces pain, provides coping skills, and improves quality of life.
CBT-CP can be administered individually or as part of a group, and in person or via telehealth.
How It Works
CBT-CP works by targeting and changing the maladaptive thoughts, emotions, and behaviors that shape an individual’s experience of pain. These mental processes can become entrenched, and CBT-CP helps to break the cycle and instill healthier, adaptive patterns.
For example, someone with chronic pain might consistently think, “I’ll never feel better, I’ll always be in pain.” That thought could lead to sadness or anger in the emotional realm, or lead them to stay home from work or socially withdraw in the behavioral realm. Those difficult emotions and avoidant behaviors could produce greater stress, muscle tension, and a flare up of pain.
CBT-CP teaches people to interrupt that harmful loop. In the example above (“I’ll never feel better, I’ll always be in pain”), the therapist might prompt the patient to think about what evidence the person has for that belief, whether there are realistic alternatives, and how to replace that hopeless thought with a more balanced one. This isn’t to deny or invalidate a person’s pain, but rather to acknowledge the pain, reduce their suffering and sense of helplessness, and live as well as they can given their circumstances.
In a related instance, someone’s catastrophizing could keep them in bed and lead to movement avoidance, which could exacerbate their pain. By using a tool called activity pacing, a therapist could work with the client to identify their current starting point and eventual end goal, such as going to work, playing with their children, or returning to a hobby they’re passionate about, like painting or soccer. The two would slowly and gradually build up the person’s activity until the person could safely meet their goal.
Tools like activity pacing and cognitive restructuring, as well as others including pain education, relaxation techniques, goal setting, lifestyle changes, sleep, physical activity, and nutrition, create an individualized approach for treating chronic pain.
What to Look for in a CBT-CP Therapist
A specific certification or license isn’t required to practice CBT-CP. Individuals should look for a credentialed mental health professional with relevant training, skills, and, most importantly, experience practicing CBT-CP.
Additionally, chronic pain is sometimes dismissed or misunderstood by healthcare providers, in part because it’s often invisible. It’s important for clients with chronic pain to advocate for themselves and find a therapist who supports them, validates them, and tries to help them in the same way they’re trying to help themselves.
