Pain management: CBT or a CBT perspective?


There is a bit of a misconception about CBT for chronic pain management. Some people think that it consists only of cognitive behavioural therapy as it is used for depression or other mental health problems. And this often means people think mainly of cognitive therapy as conducted by clinical psychologists – meaning that clinicians from other professions can lack confidence to be involved.

I thought today I’d outline the views of one of the ‘founding fathers’ of the cognitive behavioural perspective for chronic pain, Dennis Turk. In a paper by Turk and colleagues Kimberley Swanson from University of Washington School of Medicine, Department of Anesthesiology, Seattle, and Eldon Tunk, Emeritus Professor in the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, the psychological models used to conceptualize chronic pain—psychodynamic, behavioural (respondent and operant), and cognitive-behavioural are described. They also briefly review treatments based on these models.

One of the main points of this editorial paper is, in their words, ‘to differentiate the cognitive-behavioural perspective from cognitive and behavioural techniques and suggest that the perspective on the role of patients’ beliefs, attitudes, and expectations in the maintenance and exacerbation of symptoms are more important than the specific techniques.’

The cognitive behavioural perspective assumes that people with chronic pain find it difficult to function because of their belief that their pain impedes their ability to engage in activties and that they are helpless to change the situation (unless their pain changes). Therapy is therefore aimed at helping people with pain realize that they can manage activities, and provides them with skills to respond in more adaptive ways that can be maintained after treatment is terminated.

The skills that are developed include the ability to reality test assumptions and beliefs, practical ways to problem-solve within situations, establishing goals and achieving them systematically (in doing so developing mastery and confidence), and ensuring effective communication skills are used to introduce change into their social context.

Turk, Swanson and Tunk acknowledge that the specific techniques used in a cognitive behavioural perspective have not received complete empirical support. So far it looks like the assumptions and orientation of the cognitive behavioural approach matter much more than the actual methods. In time it is hoped that the particulars of the best intervention for the most appropriate situation will be identified.

In the meantime, these are the assumptions that therapy should have:

  • People are active processors of information and not passive reactors
  • Thoughts (for example, appraisals, expectancies, beliefs) can elicit and influence
    • Mood
    • Affect physiological processes
    • Have social consequences
  • Thoughts also serve as an impetus for behaviour
  • Conversely, mood, physiology, environmental factors, and behaviour can influence the nature and content of thought processes
  • Behaviour is reciprocally determined both by individual and by environmental factors
  • People can learn more adaptive ways of
    • Thinking
    • Feeling
    • Behaving
  • People should be active collaborative agents in changing their
    • Thoughts
    • Feelings
    • Behaviour
    • Physiology

For a moment, think of the work you do with the people who have chronic pain…
Do you emphasise the role of being aware of negative beliefs regarding their abilities?
Do you help them to manage pain by making them aware of the role that thoughts and emotions play in potentiating and maintaining stress and physical symptoms?
Do you encourage your patients to test how helpful their thoughts, beliefs, expectations, and predictions are? Re-set goals, work out ways to achieve targets, get through hard times, practice using coping skills like relaxation, regulating arousal levels, persisting despite fluctuations of pain?

If you can answer yes, then you’re on the way to incorporating a CBT self-management perspective.

Self-management is all about enhancing a person’s sense of self-efficacy by increasing a sense of control to combat the feelings of helplessness and demoralization often felt by people with chronic pain. It needs to be supported by all members of the health care team, and can include traditional ‘cognitive’ therapy as well as ‘behavioural’ approaches – and there are many methods that can be used.

Although there is some evidence that patients’ perceptions of control, disability, self-efficacy, harm, catastrophizing, and rumination are key mediators in whether CBT-based pain management has an effect on pain and activity (see Turner, Holtzman & Mancl, 2007), there is evidence too that other psychosocial factors moderate how well CBT-based approaches can be adopted. Turner et al. found that the number of pain sites, depression, somatization, rumination, catastrophizing, and stress existing before treatment were important. This tells me that people who are already at a disadvantage for coping, perhaps are less resilient generally, will find it harder to integrate the skills developed in CBT pain management. It also tells me that addressing pain alone, or simply the physical aspects of pain (i.e. fitness) simply will not be enough.

I was interested that although the overall effect of CBT-based pain management was modest, the results ‘were comparable to those observed with more traditional pharmacological and procedural treatment modalities.’ This means it’s likely that even people with good pharmacological pain relief will still probably need some help to move towards actively re-engaging with life. And the most effective way to do this comes from a cognitive behavioural perspective.

Pain management needs to have input from every discipline involved, in an equal footing with each other, with the person who has the pain in the centre of decision-making. This means the person with pain needs to become highly informed about options, be fully aware of the potential outcomes of each choice – and finally, to be heading somewhere instead of living from day to day (or appointment to appointment).

This is a much more positive view of pain management than simply alleviating pain – it’s so much more about achieving potential, living fully, and becoming well.

Psychological Approaches in the Treatment of Chronic Pain Patients—When Pills, Scalpels, and
Needles Are Not Enough

Dennis C Turk; Kimberly S Swanson; Eldon R Tunks
The Canadian Journal of Psychiatry, Vol 53, No 4, April 2008, pp 213-223

Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients
with chronic pain. Clin J Pain. 2002;18:355–365.

Turner J, Holtzman S, Mancl L. Mediators, moderators, and predictors of
therapeutic change in cognitive-behavioral therapy for chronic pain. Pain.
2007;127:276–286.

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