Cognitive and behavioural therapies (CBT) are not one single ‘therapy’, but a group of interventions that are combined in pain management to help the person develop ways to continue living despite their pain.
Cognitive Behaviour Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion), and how we act (behaviour) interact together. Specifically, our thoughts determine our feelings and our behaviour. Therefore negative thoughts can cause us distress and result in problems.
CBT is based on both cognitive and behavioural therapy.
Cognitive therapy – thoughts, beliefs, attitudes and perceptual biases influence which emotions will be experienced and also the intensity of those emotions. Therapy is based on modifying thoughts and therefore emotions and behaviour.
Behavioural therapy – reinforcement and imitation teaches normal behaviour, therapy is based on learning theory. Initially cognitions were ignored as having little relevance.
CBT arose from amalgamation of behaviour therapy and cognitive therapy. These therapies were developed in contrast to psychodynamic therapy, which assumed that inner conflicts in the psyche were responsible for problematic behaviour and emotions.
Skinnerian behaviourist therapy (B.F. Skinner, 1904-1990) was made popular by the thought that by applying scientific principles to behaviour, years of psychotherapy could be avoided and problematic behaviour could be changed quickly. Original behaviourists ignored or downplayed the role of thoughts, beliefs and understanding of the patient. This was mainly as an over-correction from the psychodynamic approach.
Normal learning theory developed from behaviourist theory and science shows that by reinforcing specific behaviours, the frequency of those behaviours can be affected.
What we can use from behavioural therapy is:
- That the part of the pain experience that is directly open to change is behaviour associated with pain
- To specify the behaviours we want to see more of, and those we want to see less of (i.e. to increase healthy behaviour and to reduce pain behaviour)
- To specify the environment or situations in which these behaviours occur
- To identify precursor (antecedent) factors that influence behaviour
- To identify consequent factors that influence behaviour
This is part of functional analysis and is part of our assessment process
It’s easy to see that cognitive factors also play a role in attention, learning and in attribution relevant to the experience of pain. Cognitive therapists such as Aaron Beck successfully used cognitive strategies to help people recover from depression and anxiety. It’s almost impossible to work with a person without giving them some sort of rationale for why we as therapists have recommended they participate – explanation is a cognitive intervention!
Cognitive therapy is about thoughts, beliefs, attitudes – how we attribute meaning to what we do and what happens to us. It is based on the belief that emotions are influenced by our thoughts, which are often unhelpful or even erroneous. In the same way, our thoughts are influenced by our emotions, and each of these influence and influenced in turn by our actions.
Cognitive therapists likewise use practical, real situations in which new cognitive strategies can be used – in essence a behavioural strategy.
Cognitive behavioural therapy has a long history in pain management. CBT applied to pain management is well-researched, and is one of the main areas outside of mental health that research has been conducted.
What we can use from cognitive therapy is:
- That explanation can reduce the ‘fear factor’
- That what we think, feel and do can be influenced by each other
- That we can learn new ways of thinking, feeling and doing
- That sometimes our thinking and feeling occur so quickly we are not aware of what happens until after the fact
- That some of our common sense ‘truths’ in the community are wrong – but still affect us (e.g. pain in the back is injury)
Cognitive and behavioural therapies are both used in pain management – but unlike mood or anxiety management where there are relatively established protocols, in pain management there has been less research specifying the components of therapy that are known to work, and for whom. Because of the multidimensional nature of disability arising from chronic pain, it may well be that there is no single protocol that will work for everyone. Instead, a clinical hypothesis-testing approach may be the most appropriate strategy (more details on this soon!).
CBT-based therapies are a generic tool for all health providers working in the field of chronic pain management. Relying on a single discipline (or member of the team!) to provide the ‘CBT’ is a recipe for patchy therapy, an opportunity for inadvertent splitting of the team, and more difficulty focusing on goals.