Cognitive-behavioral therapy
What is CBT?
CBT is a short-term, goal-directed form of talk therapy that addresses problems associated with chronic pain through changes in thinking, behavior, and feelings. This form of therapy has some of the strongest evidence supporting its use with chronic pain compared to other non-drug treatments. It can be obtained in either group or individual formats and typically lasts for 8–12 sessions, with occasional booster sessions every few months for maintenance of benefit.
How does CBT work?
CBT treatments exist for many illnesses including cardiovascular disease, diabetes, asthma, cancer, depression, and anxiety. The commonality of these conditions is that the goal of treatment is not to fix or cure the problem but to successfully manage it over time. When used for chronic pain, CBT helps to identify thinking and behavioral patterns that may have been helpful when pain was acute (e.g., resting, avoiding people), but are now problematic given pain is chronic (e.g., prolonged rest leads to deconditioning, avoiding people interferes with work and family responsibilities).
CBT involves a patient and a therapist, each of whom has a specific role. The patient (a) identifies problems, (b) defines goals, © learns skills, and (d) implements solutions. The therapist (a) listens, (b) helps refine goals, © teaches skills, (d) reinforces/encourages trying new approaches, (e) personalizes skills for the individual for long-term use.
By changing behaviors that can make pain worse, and by altering thinking patterns that promote negative emotions, pain can diminish and functioning can improve.
What other names might this go by?
Actual CBT requires a relationship between a therapist and patient or groups of patients. Sometimes however the skills of CBT have been put onto web-based platforms as self-help or as self-management skills without a therapist. These therapist-less or "unguided" online resources can be helpful on their own or can be used by a health coach to help individuals with pain. PainGuide is an example of one of these unguided cognitive and behaviorally based self-management resources.
Related to CBT is another form of therapy called ACT (Acceptance and Commitment Therapy) – see the ACT section for more details.
Also Related to CBT is EAET (Emotional Awareness and Expression Therapy) – see the EAET section for more details
Who can be a CBT provider?
CBT is often provided by a licensed psychologist or social worker. While many psychologists and social workers get training in CBT generally, it is recommended that you identify a therapist with advanced training in CBT for chronic pain.
CBT may also be provided by nurses, PTs, OTs or licensed professional counselors. Typically, a CBT therapist is a licensed health professional with advanced training in CBT.
CBT-related self-management skills for pain (i.e., not formal psychotherapy) however can be taught by health coaches and physician assistants and medical assistants.
Note: It is worth shopping around for a therapist with whom you can relate. Much of CBT rests upon a good therapeutic relationship between the therapist and the client.
What to expect
The first several sessions involve education and information gathering with ample time for the patient to fully tell his/her history/story of how pain started and its impact on life. The early sessions ensure that the therapist and patient share a common knowledge about how pain works within the body, agree on expectations for therapy, agree on the goals of therapy, and agree on what constitutes success/improvement.
Subsequent sessions (typically 45 minutes each) involve the therapist teaching a skill to address an issue associated with pain (e.g., sleep problems, pain intensity, negative mood, problems thinking, fatigue etc.). The skill is presented, the patient is encouraged to try the skill, and is given homework for practicing the skill between sessions. At the next session, the homework is reviewed, problems with the homework are addressed, and a new skill is introduced along with new homework. Throughout therapy, weekly monitoring of pain and function allows the patient to identify those skills that are having an impact. Near the end of treatment, the patient and therapist make a long-term maintenance plan for taking and using the most helpful skills into the future. Successful therapy is typically associated with improvements in function, decreases in pain, and confidence in using each of the skills on one's own when needed.
Potential Risks
CBT is a safe form of talk therapy for which there is minimal risk. Sometimes talking about pain can temporarily make pain seem more intense.
Resources
Many Pain Clinics will have trained CBT therapists on staff.
Association for Behavioral and Cognitive Therapies (Find a Therapist)
Website: http://www.findcbt.org/FAT/
Psychology Today (Find a Therapist)
Website: https://www.psychologytoday.com/us/therapists
Prepared by:
David Williams, Ph.D.
11.2019
