A brief review of cognitive behavioural approaches for pain management

Cognitive behavioural approaches for pain management are not exactly the same as cognitive behavioural therapy for mental health problems.  While there are some underlying concepts that are the same, cognitive behavioural approaches for pain management include a wider range of strategies, and are far less readily defined than the very structured approach used in mental health.  In fact it has only been in the last few years that research into the process of change in pain management have been conducted.

What defines a cognitive behavioural approach?

  • The assumption that people can learn to accept their chronic pain
  • That people can broaden their self-concept beyond being “a patient” into being “a person with pain”
  • That people can learn or re-explore skills to deal more effectively with their pain (Morley, Biggs & Shapiro)
  • Managing or living well despite pain
  • Pain behaviour that limits living well becomes the target
  • CBT provides the skills to (ultimately) change behaviour
  • Provided by any/all members of the interdisciplinary team (common treatment model)

What are the goals of this approach? (NB in no particular order!)

  • To reduce pain intensity
  • Increase functional activity, including work
  • Reduce/rationalise use of health care
  • Reduce distress
  • Improve quality of life

One of the main aims of this approach is to ultimately help the person with pain become his or her own therapist – to effectively self manage pain.

How do we do this?

The exact combination of strategies and approaches that “do the trick” in this kind of approach is not yet known.  It could even be that the specific techniques that people learn may not, in themselves, be all that important.  Maybe it’s the emphasis throughout treatment that there is hope for a life even if pain is present that helps patients become people again.  Research simply doesn’t tell us this yet.

Certainly, in the years that I’ve been working in pain management, the core elements have changed little, with perhaps, the addition of graded exposure and the mirrorbox and laterality work for certain problems.

How do we begin with this approach?

  • Assessing what the person with pain considers to be the main problem (the problem/s that pain “causes”, rather than pain alone)
  • Asking why he or she is looking for help right now (what were the triggers? It could be the person, or someone else who has initiated the treatment-seeking)
  • Identifying the changes he or she wants to see (how will the person know treatment has been successful?)
  • Listing the behavioural difficulties the person is currently having

Some of the ways I do this are to ask the person “what would you be doing now if pain was less of a problem?”

There’s a reason I use that phrase “less of a problem”, because I pretty much don’t refer to pain intensity again.  Pain is likely to be present and to fluctuate throughout treatment and afterwards.  I want to model that it’s the fear of pain, rather than the pain itself that is most disabling.  Even when pain is intense, it’s more helpful to relax and go “with” the pain than be fearful and tense the body to resist it.

A first step is often to introduce a model of pain and how it affects the individual.  This is a personalised model of pain, individualised for this person – but based on what we currently know about pain from research.  Various explanations can be used, but I draw from what the person tells me about their experience of pain to generate their specific model.

Most times, it seems to help people to discuss a current neurobiological model of pain – and this is often where “Explain Pain” or similar descriptions can be really helpful.  Taken at a pace that people can manage, and using their own examples, helps people to quickly grasp information that many medical students only begin to learn in 3rd and 4th year of study.

How does this step help?

Cognitive behavioural theory suggests that people appraise or judge situations very quickly, on the basis of past learning, current arousal state, and future predictions.  Automatic thoughts then generate an emotional response.  This emotional response influences behaviour.  The relationships between these four factors can be bidirectional.

By giving people a more accurate and more realistic view of their pain – as something that can be understood (at least in part), and managed, and isn’t signalling harm – people can be far less distressed by it.  You can think of how your knowledge that a flu jab is a helpful way to prevent getting the flu and how this helps you cope with the sting of the needle, and compare it with how you would interpret and respond to being stuck with a dirty needle wielded by a hoodlum in a dark alley! The thoughts and beliefs we hold about sensations influence emotions and behaviour.

Eliciting an individual’s automatic thoughts about pain, and helping them recognise that the way they view their pain may be accurate-but-unhelpful, is one part of the cognitive behavioural approach to pain management that all members of the team need to reinforce.

The remainder of a cognitive behavioural approach to managing pain is focused on helping people engage with activities they value, and doing so in a way that (1) is manageable for now and (2) recognises the sensitive nervous system can be stirred up quickly by things other than physical activity.  Skills are developed to set goals, manage gradual increases, problem solve ways around obstacles, manage arousal levels, and work with thoughts and beliefs that become stirred up by doing things differently.

What about people who are really, really fearful of moving and avoid things? Take a look at that reference below – it’s a review of the approaches that have been used for people in this situation.  More on it very soon…

Bailey, K. M., Carleton, R., Vlaeyen, J. W., & Asmundson, G. J. (2010). Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pain: A preliminary review. Cognitive Behaviour Therapy, 39 (1) DOI: 10.1080/16506070902980711


  1. This is very interesting. I recently heard an interview with Professor M Merskey who is a phsychiatrist specialising in chronic pain in Canada. He had concerns about treatment methods which he stated “devalued” the individual’s pain experience and I wondered if he was talking about CBT style programmes. I wonder if you are familiar with his work and if you have any comment on his approach as opposed to a CBT style approach. I don’t know much about his treatment methods but managed to locate an article by him entitled “Logic truth and language in concepts of pain” in a journal called “Quality of Life Reseach” V3 Supplimnet1 s69-76.

    1. I’m not sure whether you’re talking about Emeritus Professor Harold Merskey, who is very well known, and is professor emeritus in the Department of Psychiatry at the University of Western Ontario. He’s quite elderly now, but continues to practice and has a keen interest in research into language and pain, as well as being involved in IASP for many, many years.
      While I can’t comment on the approach he discussed in the interview you heard, my impression is that most of the successful pain management programmes internationally include the sort of approaches that I’ve indicated above. A cognitive behavioural approach, carried out collaboratively and within an interdisciplinary team doesn’t devalue the individual’s experience, I believe, because it helps people understand how they’re arrived at their situation in a nonjudgemental way. To me, people don’t choose to suffer or feel depressed or avoid movements. They do so because they’re making decisions based on inaccurate or inadequate information, and they’re responding because what they’ve done has worked at least once, and in the short term. My job is to help fill out some of the details, make their assumptions explicit, and identify, with them, the short and long term consequences of the decisions they make. That way the person can make informed choices about how to respond next time they’re in a similar situation.

      1. This is an interesting discussion. I actually agree that the principles you outline are important, and I very much believe in living well despite the pain. In fact, given the history of my negative comments on this blog, you probably would not believe the kind of conversations I normally carry with my family 😉 They suggest things like “take 6 months off work and go see if you can find a cure”, and it can be really difficult to explain that this is not a good plan, all medical evidence indicates that I cannot be “cured”, and my best plan is managing pain and living well.

        That said, I can very much relate to the idea that some attempts at CBT can indeed feel like they are devaluing the person’s experience or dismissing the reality of their problems. These things tend to stick around for a long time… For example, a comment from one of my doctors “You said you have trouble dancing. Think about it, what the worst thing that can happen? You will be in pain, but you will still be dancing, and can enjoy it”. This is indeed consistent with CBT. But not really true for me: if I ignore certain kinds of pain, things escalate in various ways. I get muscle spasms to the extent that is beyond my tolerance limit; or I start limping, entirely against my will, which slows me down and puts other plans in disarray for days. The end result is, no dancing – much as I loved it, I just could not tolerate the problems it caused on regular basis, problems that went beyond pain. Unfortunately, I was not able to get that particular doctor to see the issue, or perhaps to believe that it was real. He persisted in trying to “re-educate” me about pain not meaning damage, and the need to stop looking for treatments. The conversation just stopped there. He explicitly identified himself as relying on CBT techniques, by the way.

        In the end, I found my individual balance between accepting what I cannot change about my condition, and getting ongoing support in place (a combination of physical therapy and acupuncture) that helps me maintain what I consider tolerable pain levels. This is probably an issue with application rather than the theory itself, but unfortunately I found that doctors who said they used CBT more often than not came across as “lecturing about ignoring pain” rather than “listening and discussing consequences” like you describe, and feeling like my experience is indeed ignored and devalued.

        Interestingly, my current physical therapist is in the “not CBT” camp. But I notice her doing certain things, like pointing out various positive aspects when I start focusing on the negative; helping me set goals and problem-solve around things I don’t feel able doing, and getting me to try new activities. This makes me think that in the right hands CBT should be very good as well – I just haven’t really seen it work yet with health professionals who focused on it as the main method…

      2. Mary I don’t think your comments are negative! I think CBT is an effective approach – but it does need to be used in an empathic and sensitive way, and recognise first of all where the individual person is at. The thing is, we all make decisions to do things based on the best information we have at hand, and on the basis of our values. As I said, it’s when people make decisions without being aware of the short-term and long-term consequences that they can begin to inadvertently put themselves in a no-win situation. Or when they make decisions that allow one important value to be lived, but cut across another important value. For example, if one value is that you want to be with a child, but another value is that you want to be rested enough to also enjoy dancing – then you may find it difficult to do both, and in choosing to do one or the other, neither may be achieved in the way that you want.
        There are times when I, as a clinician, need to challenge someone’s assumptions that ‘there is only one way’. A good example is when I work with someone to help them see that cleaning the entire house in one go is unhelpful if they also want to be able to cook dinner that night! My job is to be gentle in helping the person see that while “doing it all” might have been possible when they didn’t have pain, now they have a limitation and maybe they can give themselves permission to do it differently. CBT is only a set of tools – it’s the clinician who uses the tools who needs to be skilled!

  2. Interesting post. I’ve also wondered to what degree chronic pain can be addressed through a 12-step/addiction model.

    The 12 step model seems to embody the paradoxical stance of both accepting and acknowledging your current status (“I’m an alcoholic”, “I’m a compulsive debtor”, “I’m a fill in the blank”) as the only way to make a shift in your situation.

    So it seems to be a way to both honor the presenting complaint while at the same time putting it into a context in which perhaps it could be modified.

    Is this what the CBT approach is getting at too?

    Ron Lavine, D.C.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.