Thursday, 16 April 2020

CBT for Chronic Pain

Cognitive Behavioural Therapy – CBT for Chronic Pain

Chronic pain affects approximately 45% of people living in the UK. This equates to over 28 million individuals suffering with pain symptoms lasting more than three months and causing significant impairment to daily life.

This article will explain how our scientific understanding of pain has developed, the difference between acute and chronic pain and the Cognitive Behavioural Therapy approaches that have been developed to significantly improve the management of long-term pain conditions.

What is Pain?

Pain is a process for alerting the body to threat and injury and an essential component of the body’s ability to repair and heal. Pain perception, however, is highly subjective and based on a complex series of interactions between biological, psychological and social factors that influence the duration, intensity and frequency of pain itself.

For this purpose, it’s often helpful to distinguish between acute and chronic pain. Acute pain is the initial signal alerting the body to injury or physical harm. Acute pain is a protective mechanism that can persist whilst the healing process continues. By contrast, chronic pain is diagnosed following a minimum of three months and after the biological healing process has happened. Although pain is still experienced, this is no longer alerting the body to further injury or damage. Acute pain can therefore be viewed as a symptom and chronic pain as a condition.

Whilst it’s relatively straight forward to apply this definition to injuries such as broken bones, there is often an overlap between acute and chronic pain and a vicious cycle of suffering in deteriorative conditions or diseases. It’s therefore important to recognise and treat the acute and chronic pain symptoms in a multidisciplinary manner; using medical, psychological and lifestyle changes to address the different facets of the pain.

To understand how CBT has been developed to support a multidisciplinary approach to pain management, it’s helpful to explore how our scientific understanding of the interplay between biological and psychological factors has evolved over time.

The Evolution of the Pain Model

The science underpinning our current understanding of pain treatment can be traced as far back as Plato - 328-347 B.C. Philosophically, Plato recognised that pain was more than a simple physical reaction, involving a wider emotional experience that continued when the stimulus was lasting or intense. It wasn’t until the 17th century, however, that a medical conceptualisation of pain was first postulated by Renee Descartes.

Descartes developed the Cartesian Dualism theory of pain in 1644, proposing that the mind was incapable of influencing the body and that pain was a purely physical phenomenon. Whilst this biological approach contributed to the advancement of medical science, it also promoted a simplistic and reductionist view of pain that influenced medical theory until well into the 20th century.

Linked to the Cartesian model, the “Specificity” theory of pain was first articulated by Charles Bell in 1811 and developed by Von Frey in 1894.  This introduced the direct connection between pain sensors, specific pain pathways and different anatomical areas of the brain. Whilst Specificity theory made a significant contribution to medical science throughout the 19th century, it continued to promote a separation of the mind and body. Many clinicians still view pain in this binary manner, treating pain as a purely physical symptom and prescribing pain relief medication on a transactional basis.

In the 1940s, pioneering clinicians including Henry Beacher and John Joseph Bonica first documented the direct influence of psychological factors on the pain levels reported by soldiers and veterans returning from the Second World War. This demonstrated a link between biological, psychological and lifestyle factors in the experience and chronicity of pain.

It wasn’t until 1965 that Melzack and Wall provided a theoretical model to explain how this interaction between biological, cognitive and emotional factors worked to influence pain perception between the mind and body.

Melzack and Wall’s Gate Control theory explained the interactions between the pain sensors known as Nociceptors, the pain gateway situated in the spinal cord and the different areas of the brain anatomically associated with the interpretation of different pain experiences.
This fundamental breakthrough in pain theory, provided the basis for understanding the complex interaction between biological injury and the cognitive and emotional factors that influence the experience and maintenance of pain itself.

Gate Control theory still provides the model through which we understand the direct links between emotions such as depression or anxiety and the intensity of pain. As Melzack said, pain is experienced in the mind. In 1977 this mind body connection was further developed through the “Biopsychosocial” model of pain introduced by George Engle and developed by John D. Loeser.

The Biopsychosocial model identified four key factors that influence our modern understanding of the experience and maintenance of pain. These are:
  • Nociception: the signal that is sent from the peripheral nervous system to the brain to alert the body to potential harm or damage.
  • Pain: the subjective experience of the pain signal as processed by the brain.
  • Suffering; the emotional response to the nociceptive pain signal.
  • Pain Behaviours: the action that the individual takes in response to the experience of pain.
The Biopsychosocial model of pain is now widely used to understand the complex interaction between biological, psychological and social factors in the maintenance of chronic pain. Research shows that chronic pain can be significantly moderated through the individual’s cognitive appraisal, emotional reaction and behavioural learning.

In spite of this, many doctors still persist in treating pain as a purely medical problem. Over the last 60 years, this has contributed to an increase in reported chronic pain levels and a marked dependency on pain relief medications. Opioid addiction and chronic pain prevalence levels have increased in tandem and are well documented in the research literature.

Empirical research has demonstrated that psychological factors including operant and conditioned learning, expectancy, memory, cognitive patterns, belief structures and anxiety / mood disorders all play a significant part in the individual’s subjective experience of pain.

Cognitive Behavioural Therapy (CBT) treatment approaches have therefore been developed to target changes in the negative thinking patterns and behaviours that maintain and exacerbate chronic pain. These approaches have been found to be highly affective in increasing pain thresholds, alleviating suffering and improving quality of life standards.

The following section in this article briefly outlines how CBT is used as part of a multidisciplinary approach to effectively manage chronic pain conditions.

The CBT Treatment Process for Chronic Pain

Cognitive Behavioural Therapy is the recommended treatment of choice for chronic pain conditions. It’s the most researched form of psychotherapy for pain and the empirical data demonstrates that it is highly effective in managing chronic pain and improving quality of life.
CBT is a practical psychological approach that helps individuals identify and alter the thinking and behavioural patterns that maintain chronic pain. It focuses on the cognitive, behavioural and context factors that maintain and amplify chronic pain.

In addition to traditional CBT approaches, a new form of CBT known as Acceptance and Commitment Therapy (ACT) has been found to be highly efficacious in the treatment of pain. This works by teaching individuals to unhook from and lower resistance to negative pain appraisals and unhelpful avoidance behaviours.

Key approaches in the CBT treatment process include:

  • Identification of pain thresholds and activity baselines.
  • Psychoeducation on the maintenance factors for chronic pain and development of a chronic pain formulation.
  • Activity pacing and management of medication schedules.
  • Multimodal relaxation training.
  • Behavioural activation and behavioural bandwidth experiments.
  • Focus of attention training and mindfulness exercises.
  • Memory rescripting – particularly where trauma is implicated.
  • Cognitive change and defusion techniques.
  • Sleep strategies to cope with pain during sleep time.
  • Relapse and resilience planning.

The above techniques are highly structured and require the support of a professionally qualified and experienced CBT specialist. Whilst there are many individuals offering CBT, our advice is to always check the credentials of the therapist by visiting the UK CBT register.

Our CBT specialists are all post-graduate qualified, experienced and fully accredited by the British Association of Behavioural and Cognitive Psychotherapy (BABCP). This means that you can be assured that you are working with a properly qualified and professionally recognised Cognitive Behavioural Psychotherapist.

You can find out more about how we deliver CBT for chronic pain conditions by visiting our page at –

You can also find a range of CBT articles, reliable information and CBT resources by visiting our website at

Disclaimer: the information in this article reflects the opinions of Think CBT and does not represent the position of any other professional / membership body.

Monday, 6 April 2020

Online CBT

Using Online Cognitive Behavioural Therapy – How to Ensure You Are Working With An Accredited CBT Expert

It’s always been important to check your therapist’s CBT credentials and clinical experience before starting Cognitive Behavioural Therapy. The increase in online CBT following the Coronavirus outbreak now means that this is more important than ever.


The title ‘Cognitive Behavioural Psychotherapist’ is not yet a protected professional term in the UK. This means that anybody can use the title without the recognised professional qualifications, training, experience or clinical supervision.

Whilst a number of well-known counselling and psychology directories offer therapist “verification”, the directory verification process can often be misleading, only applying to self-declarations and confirmation of therapist contact details.

Unfortunately, this means that there are many unqualified individuals offering CBT and counselling services without the recognised professional credentials or experience. We have seen examples of counsellors offering CBT with only a few weeks and in many cases, only a few hours of Cognitive Behavioural Therapy training.

As it’s likely that the Coronavirus isolation period will continue for many months before face-to-face therapy arrangements are back in place, this article explains how to ensure that you are working with a properly qualified UK CBT Psychotherapist. It also outlines the UK accreditation standards, so that you can properly assess the qualifications and expertise of your therapist before booking Cognitive Behavioural Therapy. You can check our online CBT services by visiting

The UK CBT Accreditation Register

The fastest and most reliable way to check that you are working with a professionally accredited Cognitive Behavioural Psychotherapist, is to check CBT credentials by visiting the UK CBT register at

This register is the only recognised quality assurance check to confirm that your Cognitive Behavioural Psychotherapist is professionally accredited by the British Association of Behavioural and Cognitive Psychotherapy (BABCP).

The BABCP is the only recognised UK professional body for the maintenance of clinical practice and training standards in CBT. The BABCP exists to protect the public and promote professional standards in Cognitive Behavioural Therapy.

The UK CBT register is used by all of the major insurance providers, the legal profession and many other professional bodies to check the accreditation status of CBT Psychotherapists before permitting panel registration. You can also visit

You can use the simple surname check to find out if your UK CBT provider is listed on the accreditation register. If your therapist is listed, you know that they have achieved the rigorous training and clinical practice standards outlined later in this article.

If your therapist is not listed on the UK CBT register, this means that they have not been professionally verified by the BABCP.

The register also offers a postcode search; however this only identifies those accredited BABCP members who have chosen to advertise their services via the BABCP’s own directory. Our advice is to find your chosen therapist and check the accreditation status using the simple surname check.

NOTE: The BABCP is often confused with the similarly sounding BACP.

The BACP is a professional body for Counselling and Psychotherapy and does not cover Cognitive Behavioural Therapy. This unfortunate similarity in names, often creates confusion for members of the public. If in doubt, always remember to check for the “double B” in BABCP.

At Think CBT, we are fully qualified and BABCP accredited.  We are also approved Cognitive Behavioural Therapy experts for all of the major insurance providers and UK panel registrants for the medico-legal and court system. You can visit our website to find a therapist at

Minimum Training Requirements and Clinical Practice Standards for BABCP Accreditation

To apply for provisional accreditation with the BABCP, the clinician must be able to demonstrate the following criteria:

·         A minimum of 12 months in a psychological core profession including HCPC registered clinical psychologist, psychiatrist or social worker. There is an extensive and in-depth clinical portfolio exercise known as the KSA assessment for applicants without a core psychological profession to demonstrate the equivalent clinical experience.
·         Completion of a BABCP approved level 2 post-graduate training programme at Master’s Degree level. Not all master’s level CBT training programmes in the UK fully meet the rigorous standards applied by the BABCP. 
·         A minimum of 450 hours specialist Master’s level CBT training. This involves written assignments, logs, case studies and research assignments amounting to approximately 25,000 words.
·         A minimum of 40 hours professional CBT supervision delivered by a recognised CBT supervisor with BABCP accreditation.
·         Presentation of eight detailed clinical cases for full clinical supervision.
·         Three written clinical case studies of 4,000 words per case study to demonstrate competency in clinical practice.
·         A minimum of 200 hours of supervised clinical work as a trainee CBT practitioner.
·         Two written references covering clinical supervision and wider professional practice.

Once these criteria have been met, the therapist may apply for provisional accreditation by the BABCP. Provisional accreditation lasts for 12-18 months, during which time the provisionally accredited CBT Psychotherapist must demonstrate adherence to the BABCP codes of practice and professional standards. This includes a minimum of 90 minutes clinical supervision each month by a recognised CBT supervisor and engagement in a further five CBT training / learning activities.

Only at the end of this period is the Psychotherapist permitted to apply for full accreditation as a CBT Psychotherapist.

What if my therapist isn’t on the UK CBT register?

Whilst there are some Psychotherapists who are able to meet the minimum training and practice standards without joining the BABCP, it’s still important to personally check your therapist’s credentials if they are not on the UK CBT register. 

If your counsellor or therapist is offering CBT services and is not professionally accredited by the BABCP, our advice is to use the following simple questions and checklist to determine whether you are working with someone with equivalent qualifications and experience:

·         How many hours of Post-graduate CBT training has the Psychotherapist completed?
(The BABCP standard is a minimum of 450 hours specialist post-graduate level training in CBT)

·         How many hours of specialist CBT supervision has the Psychotherapist completed?
(The BABCP standard is a minimum of 40 hours of CBT specific clinical supervision).

·         How many hours of supervised specialist practice has the Psychotherapist completed?

(The BABCP minimum standard is 200 hours of supervised practice as a CBT Practitioner)

·         What approved post-graduate CBT specific qualifications does the Psychotherapist have?

(The BABCP standard is completion of a level 2 accredited post-graduate training programme at Master’s level).

Some therapists have professional credentials that provide an equivalent to the above criteria without being on the UK CBT accreditation register, however it’s often difficult to compare and quality assure without independent professional advice. If in doubt, consult the UK CBT register or use the above checklist.

This is what we offer at Think CBT

If you work with a Think CBT Psychotherapist, you can be assured that you are working with BABCP accredited CBT experts and HCPC registered psychologists. We only offer services that we are professionally qualified and accredited to deliver and we only work with clients when we are confident that we can help. We quality assure our team members so that our clients don’t have to worry. You can find out how we ensure the highest standards of online CBT by visiting

As part of our recruitment process we check professional credentials, experience, qualifications, DBS clearance and professional indemnity.  All of our CBT Psychotherapists are interviewed, and we only accept CBT experts with a proven track record.

If you want advice or guidance on any of the above points, contact Think CBT via or by visiting our website at

Disclaimer: the information in this article reflects the opinions of Think CBT and does not represent the position of any other professional / membership body.

Friday, 20 March 2020

CBT During Covid

Coping With Isolation

Over the coming weeks and months, many of us will be asked to self-isolate or be instructed to stay at home if we have been infected by the Coronavirus. This will place us under significant pressure and change many of our normal coping mechanisms. So for example, if we are used to engaging in social activities such as  sports, events, bars, shopping, contact with close friends and family, we will need to develop a new approach to maintaining good psychological health to get through the isolation period.

At Think CBT we have developed a simple framework to help people plan, structure their time and act in a way that makes the period of isolation more bearable. 

This approach is called the “PACE” framework. The PACE framework draws on tried and tested CBT methods to help maintain good emotional and psychological health. You can download a free copy of the PACE Framework at PACE or by visiting our Resources page at

PACE is a simple acronym that stands for Physical, Achievement, Connection and Enjoyment.

Each of these areas are directly linked to the upkeep of different biological and emotional processes in the human body and nervous system.

Physical – This involves diet, exercise and sleep patterns.

Achievement – This is what we do to get a sense of purpose, completion or  satisfaction.

Connection – This involves our key relationships, feelings of closeness, community or  bonding.

Enjoyment -This includes the things we do for fun, for interest or pleasure.

During the period of isolation, it is important that we plan and structure our time to address each of these areas. We  should be aware of the risks of falling into patterns of unstructured and passive behaviour. Taking an unplanned or reactive approach during long periods of isolation can lead to problems with anxiety and depressed mood, which in turn can have a significant impact on our physical health. 

In-depth studies into the affects of isolation in prison or detainment populations have shown the profound affect that a loss of structure, engagement and purpose can have on psychological health and well-being.

So how do we apply the PACE framework?

Let’s take each of the four areas in turn and outline what this involves:

Physical Time – It’s important that we maintain good diet, sleep and exercise patterns.

Diet: Diet means planning and sticking to a well-balanced, varied and nutritious diet during the period of isolation. So without stock-piling, we can buy or have fresh food delivered. We can plan a weekly menu and really stretch our imaginations to try recipes that we don’t normally have the time to prepare through work or other commitments. The key to this is planning and sticking with the weekly menu. 

If you are living alone, this can involve contacting friends or checking out recipes online or on channels such as YouTube.

If you are isolated with other family members, this can be planning and preparing food together.

The important thing is to have a plan and stick with it.

Exercise: Exercise is crucially important. Mr Motivator said on the radio just this week that your home is your gym. You should make the time and space to undertake regular exercise or gentle stretching movements to physically activate the body. You can find countless online home based exercise plans by simply entering exercise at home into your search engine. 

It’s also important to remember that isolation does not mean staying at home. You should try to walk, run or take exercise outside in daylight, always taking care to maintain physical distance from other people to avoid the risk of infection.

Sleep: A healthy sleep pattern is key to good emotional balance and we know that sleep is often the first thing to suffer when we experience periods of stress. There are some strict rules about practising good sleep hygiene and bedtime rules to improve the chances of a good night’s sleep. Some key points are stick to a regular wakeful and sleep timetable, keep the bedroom clear of screens and other distractions and only go to bed when you are tired. There is a special type of Cognitive Behavioural Therapy for Insomnia called CBT-I and you can learn more about this by visiting

Achievement Time – This involves planning and  allocating time to undertake activities that give you a sense of completion or satisfaction. This can range from work-related tasks for those people working from home or school, but it can also involve domestic tasks such as tidying, cleaning, gardening, home improvements or odd jobs around the house. Make a list of those jobs that you never seem to have time to complete and use the PACE exercise which you can download from to schedule these activities.

For those of us looking after younger children, this may also involve some support for home schooling. Again, having a structured plan for schoolwork time is crucially important.

Connection Time – This is an important human need to engage and connect with other people. If you are living alone, you should reach out to friends or acquaintances, join online groups or make contact with some of the social organisations that work to eliminate loneliness. Some of the organisations that can help include:

UK Youth, The Silver Line, The Way Foundation, The British Red Cross, Age UK.

If you are isolated with other family members, you can schedule time to sit together, play games, eat together, talk through your feelings, concerns and offer support. 

Physical human contact is a highly important aspect of this, so take the time to cuddle up and exchange hugs on a regular basis. The Danish have a specific phrase called “Hygge” (pronounced hooga) where they take the time to connect, particularly when the weather is cold and inhospitable. Again the key to this is planning and scheduling daily “hooga” time, so that you spend quality time with your partner or family members without other distractions.

Enjoyment Time – This involves just doing things that are fun, interesting, fulfilling or exciting. For many people this period of isolation could be an opportunity to learn a new skill, take up a hobby, learn some key phrases in a different language, to read books that you don’t normally have the time to engage in, to watch that box-set with a good bar of chocolate or to relax in a hot bath. Make a list of the things that you really enjoy doing and schedule something enjoyable each day. This doesn’t have to be a momentous thing and could just involve a brief moment of relaxation. 

Enjoyment always has more impact when it is linked to a sense of reward for having the personal discipline to stick to your weekly plan for Physical Time, Achievement Time and Connection Time. 

You may find that some activities cross the boundaries between Physical Time, Achievement Time, Connection Time and Enjoyment Time. This doesn’t really matter provided the activities are planned in advance and applied with good self-discipline.

To find out more about the PACE approach, you can visit the Think CBT website at 

Finally, if you need specific support and feel that you might benefit from working with a professionally accredited CBT expert, you can organise online video or telephone CBT on 01732 808626 or via

Our CBT experts can provide professional guidance and support for the full range of anxiety conditions and depressive disorders. We know that the Coronovirus will be particularly challenging for people with a pre-existing anxiety condition or problem with depressed mood. Don’t suffer in silence.

We have made special provision for online Cognitive Behavioural Therapy and the research evidence shows that it can be as effective as face-to-face work. We don’t just use messenging or email contact like some other online services. Our online sessions are conducted via a video connection where the CBT materials and exercises are shared on-screen as we work with our clients. This is a fully interactive experience and we use exactly the same approaches that we use with our clients when working together in the same room.

Our online CBT page explains how the online CBT process works and provides access to free online psychological assessments. If you want to find out more about online Cognitive Behavioural Therapy, visit

Disclaimer: the information in this article reflects the opinions of Think CBT and does not represent the position of any other professional / membership body.