An overview of the CBT approach to managing pain and how it is applied in client sessions.

1. Cognitive Behavioral
Therapy
For Chronic Pain
(Health Practitioner Guide)

2. What is CBT?
• Psychotherapeutic intervention (short-term)
• Focuses on role of thoughts, emotions and behaviours
• Effective in management of chronic pain:
• Improves quality of life & functioning (Hoffman et al., 2007; Morley et al.,
1999; Turner et al.,2006)
• Helps patients gain more control &
• Adopt a problem solving approach (Murphy et al., 2014)

3. Chronic pain
• Pain is subjective
• Chronic pain: (Murphy et al., 2014)
• Persists, longer than 3 months
• Known/unknown cause
• A condition that needs to be managed not cured

4. Pain theory
• Biopsychosocial model:
Physical, psychological &
social factors (Gatchel et al., 20007)
• Family
• History
• Emotional factors
• Psychosocial influence
in pain perception (Melzack &
Wall, 1967)

5. Situation:
Pain when trying
to exercise
Thought:
“I can’t do what I
used to anymore”
Emotion:
Disappointment
frustration
guilt
Behaviour:
Inactivity
resulting in
more pain
CBT model example- Osteoarthritis

6. Interdependencies
• Thoughts (‘I should avoid moving’) can affect emotions
(frustrated) and behaviour (avoidance)
• Emotions (feeling low) can dictate behaviour and perception
of situations.
• Behaviour (not exercising) can impact thoughts (‘it’s too
hard’) and feelings (disappointment).

7. Factors that make pain worse (Murphy et al, 2014):
• Psychological:
• Negative thoughts
• Catastrophising- ‘nothing can be done’
• Belief that pain is indicative of further damage
• Belief that the pain is a mystery/answer-seeking
• Negative emotion- depression/anxiety
• Low self-efficacy/no control over pain
• Behavioural:
• Guarding/protective behaviours
• Under-activity or over-activity
• Social:
• An overly responsive significant other
• A punishing or ignoring significant other

8. Source: The American Academy of Pain Medicine (AAPM)

9. CBT Treatment for Pain
(Murphy et al., 2014; Cully & Teten, 2008)
Structure over 6-12 sessions
• 1. Assessment & interview:
• Clinical interview: Patient medical & chronic pain history, meds, pain location,
frequency & intensity.
• Clinical assessment measures: Pain rating/Quality of Life/Patient Health
scales
• 2. Building a rapport with client
• Empathy, genuineness, positive regard
• 3. Orientating to CBT model:
• Chronic pain cycle

10. CBT Structure contd..
• 4. Case conceptualisation/formulation of problems
• 5. Interventions:
• Examples: Goal setting, problem lists, problem solving, ABC worksheets,
exercise & pacing, relaxation techniques, pleasant activity scheduling,
cognitive coping strategies [challenging maladaptive thoughts & beliefs], sleep
hygiene.
• 6. Agenda setting & homework
• 7. Discharge planning:
• Review of progress, coping with flare-ups, maintaining pain management &
identifying possible barriers, how to maintain change.
• 8. Booster sessions:
• Progress update, CBT refresher.

11. References:
Cully, J.A., & Teten, A.L. (2008). A Therapist’s Guide to Brief Cognitive Behavioural Therapy.
Department of Veterans Affairs South Central MIRECC, Houston.
Gatchel, R.J., Peng, Y.B., Peters, M.L., Fuchs, P.N., & Turk, D.C. (2007). The biopsychosocial approach
to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-
624.
Hoffman, B.M., Papas, R.K., Chatkoff, D.K., & Kearns, R.D. (2007). Meta-analysis of psychological
interventions for chronic low-back pain. Health Psychology, 26(1), 1-9.
Melzack, R., & Wall, P.D. (1967). Pain mechanisms: A new theory. Physiology, 11(2), 89-90.
Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized
controlled trials of cognitive behavioural therapy and behaviour therapy for chronic pain in
adults, excluding headache. Pain, 80 (1-2), 1-13.
Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D., & Karlin, B.E. (2014). Cognitive
behavioural therapy for chronic pain among veterans: Therapist manual. Washington, DC:
U.S. Department of Veteran Affairs.
Turner, J.A., Mancl, L., & Aaron, L.A. (2006). Short- and long- term efficacy of brief cognitive-
behavioural therapy for patients with chronic temporomandibular disorder pain: A
randomized, controlled trial. Pain, 121(3), 181-194.