Ease Chronic Pain with Cognitive Behavioral Therapy

CBT teaches you the answers to your problems!

Cognitive behavioral therapy (CBT) is a kind of talk therapy – but it's not introspective or historically-focused.

1. In CBT you look for solutions to a current problem and then you learn effective techniques to put these solutions into practice.
2. So if you struggle with pain that’s not going away (the problem) learning techniques that help you cope with pain (the solution) makes a lot of sense.

CBT isn't always focused on reducing pain; sometimes pain-reduction happens as a side effect. CBT gives you effective tools to manage and cope with pain so you can get out and enjoy life - whether your pain goes away or not. Fortunately, as you increase your activity level, reduce stress, sleep better and stay more positive and hopeful, you'll likely also see a substantial pain reduction.

Why Does Maladaptive Thinking Increase Pain?

Your medical condition causes you pain – but social, environmental and psychological  factors influence your perception of pain. If you can’t eliminate pain, you can still sometimes alter your pain experience through changes to thinking and behaviors.¹

The way you think about pain affects your perceptions, and if you fall into maladaptive pain thinking habits, you can actually think your way into greater discomfort.²

For example:

• If episodes of back pain normally last for days and leave you bed-ridden, the first unusual twinge in your back might prompt worst-case scenario predictions of the pain that you’ll be in, the plans you’ll have to cancel and all the work you won’t get done.
• These thoughts increase stress and anxiety and cause the release of stress hormones, a blood pressure spike and increased muscle tension. These physiological changes can cause or exacerbate pain.
• Physiological responses to stress and anxiety make it more likely that an innocuous twinge turns into a severe pain episode and/or something that increases disability.

The way you think matters! Here's a short list of some non-medical variables that worsen pain and disability:

• A strong fear of pain or of re-injury.
• A strong avoidance of activities that might be painful or reinjure - resting too much and for too long after injury or pain.
• Catastrophizing (worse case scenario thinking).
• Excessive use of passive pain relief (an over-reliance on medication, resting, etc.).
• Depression.
• Stress – chronic pain often causes financial worries, anxiety about meeting responsibilities and guilt feelings related to failing to meet responsibilities.
• Poor concentration and muddled thinking – pain can leave you distraction-prone and memory-short, this can compound the problems you already have in meeting your daily responsibilities and can lead to feelings of helplessness, anxiety and depression (all of which can worsen pain perception).
• Poor problem solving.
• Poor use of coping strategies, for example, insufficient pacing – pushing yourself to exhaustion one day and needing to spend the following 2 days recovering and in pain.
• Receiving overly responsive home caretaking.

This short list of examples demonstrates how non-medical variables can have a profound impact on your pain experience and quality of life.

Fortunately, if you look at this list from a CBT perspective, you see a list of solvable problems - and a huge opportunity for pain reduction!

What CBT Can Teach You

Some common pain CBT goals include:³

1. Learning to become an active pain management problem solver.
2. Learning to stop living in the past, pining for what you used to be able to do. By living in the present you can focus on problem solving and adapting to your limitations to create the best life you can today.
3. Learning how negative thinking can worsen pain and then learning how to monitor and change thoughts as needed to avoid worsening pain.
4. Learning effective pain management skills and incorporating these into daily life (relaxation exercises, journaling, etc.)

Here are some examples of CBT techniques you might learn to solve pain-problems. Most of these are fairly easily understood – the real trick is in putting these easy techniques into regular daily practice.

Changing Unhealthy Thinking Habits

Most people make use of one or more unhealthy and unhelpful thinking habits, and when it comes to chronic pain, maladaptive cognition leads to extra aches and pains.

Some examples of maladaptive thinking habits include:

• Catastrophizing – predicting the worst case scenario.
• Black and white thinking – forgetting that reality is composed of many shades of gray.
• Unrealistic expectations for the world - (should statements).
• Mind reading – believing we know what others are thinking about us.
• Emotional reasoning - believing our feelings indicate truth. Believing that if we feel worried about our pain that means our pain is causing harm.

CBT Tools That Reduce Pain

Scheduling

With pain, it’s easy to lose life-balance - for example, you have less energy so you spend it all at work and have nothing left for fun or social relationships.

To get back in balance, take stock of what’s important in your life (for example: achievement at work, school or volunteering, social outings and relationships, hobbies and fun) and then schedule your days so that you find time for all of what's most important, making sure to include ample time for rest along the way.

• Active planning ensures that you fill your time with what’s most important and helps you eliminate the tiring less important stuff. 

Relaxation Training

Stress and tension increase pain and anxiety; learning relaxation techniques helps you keep pain under control by reversing much of the stress and tension that cause it.

Some examples of relaxation techniques/exercise you might learn include:⁴

• Deep breathing exercises.
• Progressive muscle relaxation.
• Yoga.
• Meditation or mindfulness.
• Imagery techniques.
• Many others.

Pacing Techniques

To live well with chronic pain you need to get out of the cycle of overdoing it when you feel well and then paying the consequences for days thereafter.

You can break this negative cycle with pacing techniques. Some components of chronic pain pacing include:

• Keeping an activity log to identify pain and fatigue patterns (for example at certain times each day or after certain regular activities.)
• Planning activities (with scheduled rest periods) to end before you get over-tired.
• Monitoring your activity log over time to identify which activities help and which worsen pain and fatigue, and then adjusting your routines accordingly. 

Problem Solving Techniques

Poor problem solving leads to stress and stress worsens pain, so learning a few structured problem solving techniques can help a lot. Here's one common 7 step method:⁵

1. Decide if this is a solvable problem or an unsolvable problem.
2. If it's solvable – brainstorm a list of possible solutions or options.
3. Pick the best solutions or options from your brainstormed list.
4. Take the top 3 or 4 options and write down the advantages and disadvantages of each option.
5. Decide on an option/solution.
6. Take action.
7. Revisit after the fact to evaluate the success of your chosen solution. 

Professional Help or On Your Own?

There are advantages to working with a CBT counselor or joining a pain group to learn CBT techniques, but if these aren’t accessible in your area or if you just prefer the idea of doing it on your own, you can also learn CBT techniques through self help books or through online learning programs. CBT is one type of intervention that you really can learn ‘on your own’.

Two examples of free online CBT programs are Mood Gym and Living Life to the Full,  though there are many other good options for this.

Treatment Duration

CBT is a solution-focused time-limited therapy. A typical course of CBT for chronic pain might occur over 10 to 15 once or twice a week hour long sessions, though people with more significant pain and disability may require more intensive therapy.⁶

Research Proving Effectiveness

Many studies illustrate CBT’s effectiveness as a pain treatment, such as:

The Cochrane Review of CBT for Chronic Pain

A Cochrane Summaries study collected data from 35 quality research trials conducted on CBT and behavioral therapy for chronic pain. Based on these studies, the researchers concluded that CBT decreases catastrophic thinking, disability and distress and improves mood. Changes were small to moderate in magnitude.⁷

CBT Increases Grey Matter

Chronic pain conditions are often associated with grey matter loss in the brain, fortunately, these losses are reversible – researchers have shown that when surgical procedures ease pain, grey mater size and density returns to normal.⁸

CBT, it seems, has the same effect. Researchers at Duke and The University of Vermont found that people with chronic musculoskeletal pain had significantly increased grey matter density after just 11 weeks of group CBT.

So not only does CBT cause perceived pain reductions, we can also see these changes with an MRI scan. 

CBT Risks and Side Effects?

All medications come with risks and side effects – especially potent opioids.

Cognitive behavioral therapy has no adverse risks, side effects or interaction effects, and by learning better mental and behavioral management of pain you may need less medicines.

Is CBT Right for You?

Most people with persistent pain can benefit from learning better coping skills and thinking strategies, especially people who:⁹

• Have lived with chronic pain lasting 6 months or longer.
• Feel that pain rules their life.
• Feel frustrated at persistent pain for an injury that should have healed.
• Find that pain gets worse with stress or anger.
• Feel hopeless about their ability to live with pain or to manage pain.
• Don’t get full pain relief from pain medication (even at maximum doses).
• Find that pain has a negative impact on social life and important relationships.
• Miss work due to pain.
• Have pain related sleeping problems.
• Find that life isn’t as enjoyable due to pain.