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.

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