CBT for Chronic Pain: How It Works, Techniques, & Effectiveness

Cognitive behavioral therapy (CBT) is an effective treatment alone for chronic pain or in addition to other methods of pain management. CBT may be especially beneficial for those struggling with problematic or distressing emotional or behavioral reactions to pain, or those who are not getting expected results from other treatments.¹ In fact, CBT studies for chronic pain have shown improvements to mood and disability status not possible through other forms of treatment.²

What Is Cognitive Behavioral Therapy?

Cognitive Behavioral Therapy is a brief therapy approach for treating a wide range of mental and behavioral issues. The basis of CBT is the cognitive triangle which illustrates the bidirectional interaction between thoughts, behaviors, and feelings. This means that our thoughts, feelings, and behaviors all impact each other, so making a change to thinking or behavior will have an effect on the other two components. Therefore, CBT interventions target either thoughts or behaviors in order to interrupt the problematic cycle that is happening.

How Does Cognitive Behavioral Therapy for Pain Management Work?

CBT for chronic pain focuses on making cognitive and behavioral changes to disrupt the problematic cycle of thoughts, feelings, and behaviors responsible for pain. While it may not get rid of the pain entirely, changing some of these thoughts or behaviors can help to decrease the pain over time.

Behavior Change

Some CBT techniques focus on changing behavior. This may look like scheduling pleasant activities or exercise. By making changes to behavior, there is a resulting change to thoughts and feelings. For example, engaging in an enjoyable activity will lead to positive feelings and thoughts.

Cognitive Change

Cognitive change focuses on education and identifying and challenging unhelpful thought patterns. Perhaps the person experiencing chronic pain has thoughts about never feeling good again. A CBT therapist may point out that this type of thinking fits an ‘all or nothing’ thinking pattern and then teaches the client how this type of thinking impacts their feelings and behaviors. The therapist may then engage the client in reframing their thoughts resulting in changes to thinking and consequently changes in behavior and feelings.

Addresses the Complex Presentation of Pain

Pain usually presents with many other problems that complicate treatment such as depression, anxiety, and borderline personality disorder.^3,4 CBT is effective in treating all of these potential underlying mental health diagnoses in addition to its effectiveness with treating chronic pain.

CBT Techniques for Chronic Pain

There are a number of CBT techniques for managing chronic pain. CBT is an umbrella for various types of therapy and techniques that have their basis in the cognitive behavioral approach, such as Acceptance and Commitment Therapy, or ACT.² All the approaches explained below would be introduced by the therapist using psychoeducation prior to implementing the techniques.

CBT techniques for pain management include:

Mindfulness for Chronic Pain

When someone experiences chronic pain, they tend to worry about the future or dwell on unpleasant past experiences. The mindfulness approach to chronic pain is about shifting focus to the present moment and noticing thoughts, feelings, and sensations without judgment.⁵

Acceptance & Commitment Therapy for Chronic Pain

ACT is driven by the concept of psychological flexibility. It differs from CBT for chronic pain in that it focuses on changing the relationship with thoughts, feelings, and behaviors associated with pain rather than on changing the thoughts, feelings, and behaviors themselves. The therapist will help the client explore, identify, and connect with their values and goals rather than being consumed by their experience of pain.⁶

Relaxation Training

There are many types of relaxation techniques that can be explored such as progressive muscle relaxation, deep breathing, and guided imagery. Chronic pain results in chronic stress on the body so practicing relaxation regularly can mitigate the impact of chronic pain on the body.¹

Cognitive Restructuring

Chronic pain can lead to or worsen unhelpful thinking patterns. Cognitive restructuring aims to identify these problematic thoughts and the situations when they arise. Then, the therapist and client will work to challenge or reframe the thoughts in order to change the impact they have on feelings and behavior.

Activity Scheduling

Those who experience chronic pain may become isolated and inactive due to fear of worsened pain. Activity scheduling is a way to increase the client’s engagement in rewarding activities by identifying and scheduling pleasant activities. For an added benefit, the therapist may encourage the client to schedule time with positive social supports. Increased activity is beneficial for both physical and mental health.

Pacing

This technique involves identifying activities that the client tends to overdo resulting in worsened pain. The client will be asked to think about how long they can do the activity before they experience pain. Then, the therapist will assist the client in setting a schedule that includes the amount of time that the activity can be tolerated before pain is likely to be experienced, followed by a period of rest. For example, 10 minutes of mowing the lawn followed by 5 minutes of rest and repeat as necessary.

Examples of CBT for Pain Management

CBT can be used to manage various types of chronic pain effectively.¹ Based on the assessment of the client’s presentation by the therapist, techniques can be tailored to each individual’s unique needs.

Migraine

CBT for managing headaches or migraines will likely involve stress reduction or stress management techniques. These techniques may take the form of cognitive and behavioral work such as identifying situations that cause the highest levels of stress and the thoughts related to the situation. From there, the therapist can engage the client in cognitive restructuring or challenging the unhelpful thoughts.

Alternatively or in addition to cognitive work, behavioral strategies such as teaching and practicing relaxation methods may be employed. CBT for chronic pain usually requires about 10 sessions with variability based on the client’s presentation and progress.

Arthritis

Pacing is commonly used to address arthritis pain as this technique helps clients learn how to manage their activities taking into consideration their ongoing pain. The therapist may combine pacing with other techniques, such as cognitive restructuring, in order to address the underlying unhelpful beliefs clients have about their pain. As with most CBT for chronic pain, treatment will likely take about 8-10 sessions.

Back Pain

Mindfulness based CBT is a technique that may be used for treating chronic back pain. There are many mindfulness exercises but the general concept of mindfulness is shifting the client’s focus to the present moment. The therapist will guide the client in noticing and observing different sensations without judgment. Mindfulness for chronic pain usually takes about 8 sessions.

Is CBT Effective for Chronic Pain Management?

There is a body of evidence supporting the use of CBT for the management of chronic pain. If you’re interested in learning more about the research into CBT for chronic pain, check out the articles listed below.

• Unlearning chronic pain: A randomized controlled trial to investigate changes in intrinsic brain connectivity following Cognitive Behavioral Therapy
• Psychological approaches to chronic pain management: evidence and challenges
• Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis
• Mindfulness Meditation and Cognitive Behavioral Therapy Intervention Reduces Pain Severity and Sensitivity in Opioid-Treated Chronic Low Back Pain: Pilot Findings from a Randomized Controlled Trial

How to Get the Most From Cognitive Behavioral Therapy

It can be difficult for those experiencing chronic pain to make changes to their thinking and behavior out of fear that a change may worsen their pain. If you are going to do CBT, it is important to be prepared to make changes and be willing to continue practicing these new skills outside of therapy.

To get the most out of CBT therapy:

• Do homework assignments between sessions
• Be willing to try something new
• Come to therapy ready to discuss what you practiced
• Be honest with your therapist about your experience
• Keep all your providers aware of changes in your treatment

Finding a Cognitive Behavioral Therapist

There are many ways to find a therapist such as asking a trusted provider for a referral, exploring therapists that are covered by your insurance, and checking online directories. In order to find a therapist, it can be helpful to check out an online therapist directory to filter for therapists skilled in CBT.

How Much Does CBT Cost?

The cost of therapy varies greatly depending on where you live, how you will be paying for your sessions, and the provider you choose. CBT is typically covered by insurance because it is an evidence based treatment for depression, chronic pain, and borderline personality disorder.

Final Thoughts

Chronic pain is tiring and can feel overwhelming. Fortunately there is a strong evidence base for using CBT to treat chronic pain. If you need help managing your chronic pain, don’t hesitate to seek out professional assistance. You may find that CBT on its own or in addition to other treatment methods is beneficial.

By Natalie J. Fraize, LMHC