A Magical Cure for Pain?

Pain hurts. CBT can help.

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Cognitive Behavioral Therapy (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). However, many of us have never even heard of it. If we have, it's only in the context of anxiety or depression - not pain. This is because 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. This stigma is real and must be addressed, especially because many of us, women and minorities in particular, ARE told the pain in "all in our heads." But this stigma ultimately prevents appropriate treatment and care. Because when combined with other interventions, brain-based approaches like CBT really do work.

And science proves it.

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 percent of the time. Neuroscience confirms that negative thoughts and emotions amplify pain, while positive thoughts and emotions turn pain volume down (Flor, 2014; Martucci and Mackey, 2018). To effectively treat chronic pain, we must therefore change the brain.

CBT can alter both brain and body, neuroscience and biology, calming the pain system and increasing functioning (Davidson and colleagues, 2003; Petersen and colleagues, 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 and Sudak, 2017). It’s been shown to significantly reduce pain intensity and disability, while improving functionality and quality of life (Adronis and colleagues, 2017; Murphy and colleagues 2020; Pigeon and colleagues 2012). It’s also associated with a reduced need for pain medications, including opioids (Garland and colleagues, 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 and colleagues, 2016), National Academy of Medicine (NAM, 2017), FDA (2017), Pain Task Force (Tick and colleagues, 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 and colleagues, 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.

Cognitive Behavioral Therapy Essential Reads

Skills That Feel Worse May Work Best for Long-Term Recovery

How to Combat Irrational Thoughts

*This article is adapted from The Pain Management Workbook, a CBT-based book for patients living with pain and the providers who treat them.