Three letter acronyms and what they mean – CBT, DBT, CFT, ACT – not alphabet soup!


Once you begin to dip your toes into psychological therapies, it doesn’t take long before you begin to see TLAs all over the place. So today I’m going to post on two things: some of the TLAs, and why or how we might consider using these approaches in pain rehabilitation.

The first one is CBT, or cognitive behavioural therapy. CBT grew out of two movements: behaviour therapy (Skinner and the pigeons, rats and all that behaviour modification stuff), and cognitive therapy (Ellis and Beck and the “cognitive triad” – more on this later). When the two approaches to therapy are combined, we have cognitive behavioural therapy where thoughts and their effect on emotions and actions are the focus of therapy, with a secondary focus on behaviour and how behaviour can be influenced by (and influence) thoughts and emotions.

In pain rehabilitation, cognitive behavioural therapy is used primarily by psychologists, while a cognitive behavioural approach is what underpins most of the multidisciplinary/interprofessional pain management programmes. These programmes were very popular and effective during the 1980’s and 1990’s, but have faded over time as insurers in the USA in particular, decided they were expensive and should instead be replaced by what I call “serial monotherapy” – that is, treatments that were provided in a synthesised way within interprofessional programmes are often now delivered alongside or parallel to one another, and typically with very limited synthesis (or case formulation). A question yet to be answered is what effect this change has had on outcomes – my current understanding is that the outcomes are weakened, and that this approach has turned out to be more expensive over time because each discipline involved is seeking outcomes that fit with their priorities, and there is far more opportunity for duplication and gaps in what is provided.

Cognitive behavioural approaches underpin the “Explain Pain” or pain neurobiology education approach. The theory is that people who hold unhelpful beliefs about their pain can become fearful of what the pain means. Once they hold more helpful or realistic beliefs about their pain, that emotional zing is reduced, and it’s less scary to begin moving.

Cognitive behavioural approaches also underpin cognitive functional therapy. In cognitive functional therapy, as a person begins to move, the therapist asks about what’s going through their mind, and establishes through both movement experiments and information, that they’re safe to move, and can do so without fear (O’Sullivan, Caneiro, O’Keeffe, Smith, Dankaerts, Fersum & O’Sullivan, 2018).

When carrying out graded exposure, in the way that Vlaeyen et al describe, a cognitive behavioural approach is integral. In this approach, the classic relationship between avoidance and a stimulus (bending forward, for example), is challenged in a series of behavioural experiments, beginning with movements the person fears the least, and progressing over time to those the person fears the most.

There’s good evidence from psychological therapies, and also from within pain rehabilitation research, that it’s the behavioural aspects of therapy that do the heavy lifting in pain rehabilitation (Schemer, Vlaeyen, Doerr, Skoluda, Nater, Rief & Glombiewski, 2018).

And, in the words of Wilbert Fordyce, psychologist who first started using a behavioural approach for persistent pain management “Information is to behaviour change as spaghetti is to a brick”.

So don’t expect disability (which involves changing behaviour) to shift too much without also including some strategies for helping someone DO something differently. And if a person doesn’t accept what you’re telling them – sometimes it’s more effective to try helping them do things differently first, and use that experiential process rather than talk, talk, talking.

ACT (acceptance and commitment therapy), and DBT (dialectical behaviour therapy) are both what is known as “third wave” cognitive behavioural therapies. They both involve understanding the relationship between thoughts, emotions and behaviours, but add their own flavours to this. In the case of ACT, the flavour that’s added is “workability” and contextual behavioural analysis, with relational frame theory as the underpinning theoretical model. Instead of directly tackling the content of thoughts, ACT focuses on changing the relationship we have with thoughts, and shifts towards using values as directing the qualities of what we do (McCracken & Vowles, 2014). Dialectical behavioural therapy helps people build social relationships that support them, begin to recognise strengths and positive qualities about themselves, recognise unhelpful beliefs about themselves and shift towards more helpful beliefs, and to use coping strategies to help soothe and calm emotional responses. I draw on ACT as my primary framework for pain rehabilitation (actually for my own life too!), but I haven’t seen as much use of DBT in this area.

Compassion focused therapy, the other CFT, is also a psychotherapy designed to help people become compassionate towards themselves and others. The theory behind this are understanding three main “drives”: the threat and self-protection system, the drive and excitement system, and the contentment and social safeness system. When these are under-developed, or out of balance, unhelpful behaviours and unhappiness occur. CFT aims to help people bring the three systems into balance. Given that many of the people who experience persistent pain have also experienced early childhood trauma, and concurrently endure stigma and punitive responses from those around them because of their pain, CFT offers some strategies to help effect change on an unsettled and fearful system. CFT uses self appreciation, gratitude, savouring, as well as mindfulness (non-judgemental awareness), and compassion-focused imagery to help soothe the system (Penlington, 2019; Purdie & Morley, 2016).

Along with these TLAs, you can also find many others. I think for each approach, understanding the theory behind them is crucial. While some of these approaches appear very “psychological”, whenever we begin unpacking them, we can start to see how most of what we offer in physical or occupational therapeutic approaches require us to draw on them.

Skills like guided discovery, motivational interviewing, goal-setting, values clarification, graded activity, helping people experience difference in their own lives, soothe their own body, become more comfortable with a sense of self that has to grapple with pain – unless we’re knocking our patients unconscious, we’re going to be using these so-called “psychological” skills.

If we are doing good therapy, I think we need to be as excellent as we can in all the skills required. This includes being excellent at the way we thoughtfully and mindfully use communication.

Psychological therapies all incorporate communication, and responses to people who are fearful of something. Most of us are involved in helping people who are afraid of their pain – and as a result are not doing what matters to them. If we don’t help people do what’s important in their lives, what on earth ARE we doing? For this reason, we need to employ the most effective tools (ie psychological approaches) in just the same way we use goal-setting (psychological), respond with encouragement to someone attempting a new thing (psychological), start with something the person can only just do, then grade it up (psychological), help down-regulate an overly twitchy nervous system (psychological), teach new skills (uh, that’s quite right, psychological!). I could go on.

What don’t we do if we’re using psychological strategies? We don’t dig into deep trauma, substance abuse, criminal behaviour, self harm, psychopathology. Though, we do address some psychopathology if we recognise that depression and anxiety both respond quite nicely to scheduling positive activities, and meaningful movement (ie exercise). Perhaps our artificial divide between “physical” and “mental” needs to be altered?

McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178.

O’Sullivan, P. B., Caneiro, J. P., O’Keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O’Sullivan, K. (2018). Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical therapy, 98(5), 408-423.

Penlington, C. (2019). Exploring a compassion-focused intervention for persistent pain in a group setting. British journal of pain, 13(1), 59-66.

Purdie, F., & Morley, S. (2016). Compassion and chronic pain. Pain, 157(12), 2625-2627.

Schemer, Lea, Vlaeyen, Johan W., Doerr, Johanna M., Skoluda, Nadine, Nater, Urs M., Rief, Winfried, & Glombiewski, Julia A. (2018). Treatment processes during exposure and cognitive-behavioral therapy for chronic back pain: A single-case experimental design with multiple baselines. Behaviour Research and Therapy, 108, 58-67.

Toye, F., & Barker, K. (2010). ‘Could I be imagining this?’–the dialectic struggles of people with persistent unexplained back pain. Disability and rehabilitation, 32(21), 1722-1732.

Veehof, M. M., Trompetter, H. R., Bohlmeijer, E. T., & Schreurs, K. M. G. (2016). Acceptance-and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cognitive behaviour therapy, 45(1), 5-31.

5 comments

  1. Bronnie, it needs to be pointed out that the “Explain Pain” or the pain neurobiology approach is underpinned by the theoretical position known as “neuroessentialism”.

    Neuroessentialism is the view that the definitive way of explaining human psychological experience is by reference to the brain and its activity from chemical, biological, and neuroscientific perspectives [Schultz 2015].

    This view can be summarised as “for all intents and purposes, we are our brains” and “mental processes are either identical with brain processes or exclusively realized by brain processes” [Schultz 2015].

    In his seminal paper, Moseley [2003] prefaces his approach by making it clear “that there are assumptions underlying the present approach that have not yet been validated and this paper is occasionally speculative for the sake of clinical relevance.” An understatement if ever there was one.

    A fundamental principle of the approach he adopts is that “pain is produced by the brain when it perceives that danger to body tissue exists and that action is required” and that “all dimensions of pain serve to promote this objective.”

    This neuroessentialist view of pain has been carried forward into the popular book “Explain Pain” that Moseley co-authored with his colleague David Butler [Butler & Moseley 2003].

    In Chapter 2 they write: “As part of the brain weighs the world, it makes a value judgment on the inputs and responds … When you are in danger, the brain calls upon many systems to get you out of trouble.” (p.43)

    On the following page readers are reminded: “if the brain concludes you are in danger, it will produce pain.” Furthermore, neuroessentialism “explains” chronic pain as an output of a disordered brain insofar as it can only be produced when the brain has decided that the person is in danger, even when there is no obvious evidence of such danger.

    But just how does “the brain” perceive or weigh or call on or conclude or decide anything?

    The implication of this approach is that the experience of pain is reducible to chemical and/or electrical activity in the brain. This may well be so – but until the problem of consciousness is solved, this line of argument simply cannot be taken further and must therefore remain is the realm of speculation. The question then arises, how useful a heuristic does it provide?

    Schultz also raises the humanistic implications of mental health professionals adopting neuroessentialism, which may be relevant to health professionals working in the field of chronic pain. They will not be discussed here.

    However, perhaps it is time that the views of Moseley and Butler on pain are challenged on a number of legitimate grounds.

    References:

    Butler DS, Moseley GL. Explain Pain. Adelaide: Noigroup Publications, 2003.

    Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther 2003; 8: 130-140. DOI:10.1016/S1356-689X(03)00051-1

    Schultz W. Neuroessentialism: clinical considerations. Journal of Humanistic Psychology 2015; 58(6):1-33. DOI: 10.1177/0022167815617296

    1. I understand your points, John, and to a large extent I agree. Would you apply the same argument to the proposals made by Melzack and Wall in their 1965 paper – where pain is considered to be an experience produced by an interaction with the brain and ascending/descending neural activity but influenced by as-yet unknown “other things”?

      I completely agree that until the hard question of consciousness is answered we won’t know (and some people argue strongly that the predictive processing model does just that – but I’m not entirely convinced).

      The point I am making in this paper is that irrespective of the metaphor, analogy or model put forward as an explanation to people with pain is almost irrelevant, until the person begins doing things differently (through observable behaviours). Behaviour change doesn’t necessarily emerge from more information or education.

      And my other point is that if information alone doesn’t do the trick, we can still help someone pursue what matters in their life if we can help them change what they do. And typically this involves invoking the behavioural paradigm. This is exactly the paradigm that so many people in the 1970’s and 1980’s decried because it was viewed as unempathic, punitive and heartless. For what it’s worth, there were plenty of times the behavioural approaches were employed in a harsh way – but the principles of behaviourism when carried out with empathy are effective.

      As someone who read Melzack and Wall when I was first given a chronic pain diagnosis and then managed to learn to live well with my pain (and without being able to influence intensity or location), I want to argue that whatever metaphors we employ, in the end they are only convenient hooks to help the person begin to recognise their experience is not static. The meaning of their pain is less about tissue state and more about “noise in the system” (I think of it as a de-tuned radio station full of static, or a phone line with interference). And furthermore, our “explanations” are intended to help people feel less distressed and more in control of their lives. This will only be helpful if clinicians are careful to monitor the effect of their messages, and become less attached to whatever metaphor is current.

      I’m not sure an all-out challenge of the Moseley and Butler approach is warranted: there is much that is positive about this model, but like every model it has limitations. To me, the primary limitation is that there remains a strong belief that experiencing pain is a bad thing, that all pain should be reduced or eliminated, and that this can happen primarily if a person hears the “right” kind of information. And I doubt this is the intention of the authors, but rather an over-interpretation by some of their followers (though the second point, that all pain should and can be reduced/eliminated is certainly a central tenet in this platform).

      As I’ve said in other places, until there are studies showing 100% success pain elimination for all, we will continue to need to develop good ways of telling people that their pain will likely remain. And that is a question I have yet to see discussed openly.

      Yet it is the key question for me: is it reasonable to provide only an empathic ear, and leave people feeling that yes, pain will remain and there’s nothing I can do about my misery? Or are there other things we can do? My answer is that yes, we can do much more to help people live well despite their experience of pain, but that this work can be challenging for both clinicians and most especially the person living with pain.

      My approach is to delve into historic approaches, like behaviourism, and integrate with modern knowledge about how we develop language and concepts (relational frame theory), to offer people “wiggle room” to begin to explore flexible ways of doing what matters. By changing our relationship to pain – from OMG that’s a threat! to OMG it’s noise in the system – we might have an opportunity to help people feel much more positive about their future.

      1. Bronnie, in answer to your first question, I would not apply the same argument to the proposals made by Melzack and Wall in their 1965 paper.

        As you would no doubt be aware, others, including the late Patrick Wall, offered reasoned criticisms of their ground-breaking hypothesis: https://www.bmj.com/content/bmj/2/6137/586.2.full.pdf

        But the “gate control” hypothesis has stood the test of time and remains a very useful heuristic.

        However, I cannot say the same for the pain neurobiology approach as championed by Butler and Moseley under the “Explain Pain” banner.

        The humanistic implications of their approach are certainly worth exploring and any efforts to do so should not be construed as making an “all-out” challenge.

      2. Are we comparing apples with apples in this case? Explain Pain as an approach is a clinical metaphor, while gate control theory was a neurobiological model. Both can be mis-used. I’ve heard gate control theory being employed in very unhelpful ways, while I’ve heard EP employed in very helpful ways. Context is everything.

  2. Bronnie, they were both conceived in the realm of neurobiology. I have not made any comment as to how they have been applied (or misapplied) in the context of health professional or consumer education.

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