Cognitive Behavioral Therapy Reframes the Experience of Chronic Pain
Chronic pain is more than a sensation. It can be overwhelming and pernicious, affecting virtually every aspect of life, from physical and mental health to work and relationships. For people living with the condition, hearing "it's just in your head" from a well-meaning acquaintance can be as infuriating as it is unhelpful. However, while the power of positive thinking seems an unlikely elixir, research suggests it may bear some promise when administered in the form of cognitive behavioral therapy (CBT).
"Cognitive behavioral therapy helps people struggling with chronic pain improve their quality of life in multiple ways," said Paul Greene, clinical psychologist, cognitive behavioral therapist, and director of the Manhattan Center for Cognitive Behavioral Therapy. "It helps people address pain-relevant thought patterns and helps them learn behavioral skills that improve pain, like activity pacing. It also helps them understand and address other factors that contribute to their experience of pain."
Pain and the brain
Pain is the brain's warning signal. When you fall and cut your knee, the peripheral nervous system sends signals to the brain that something's amiss, prompting you to address the threat. This localized sensation is known as peripheral pain and it usually dissipates as the body heals.
Recent research demonstrates the brain can misfire and continue to sound alarm bells long after the danger has passed. This type of pain, known as "centralized pain," is facilitated by the brain and spinal cord.
Leslie J. Crofford, M.D., explored centralized pain and treatment obstacles in an essay published in Transactions of the American Clinical and Climatological Association titled, "Chronic Pain: Where the Body Meets the Brain."
Crofford writes that centralized pain is "perceived pain" with an unidentifiable cause or one that can't be fully explained. It occurs because of "physiologic alterations in pain transmission or descending pain modulatory pathways."
Essentially, there's a communication breakdown between the brain and body, causing the brain's emergency switch to remain in a permanent "on" position.
As Crofford explained, psychological and behavioral responses to pain can amplify it. Chronic pain, and a person's response to it, can exacerbate issues like stress, anxiety, fatigue and depression, which can, in turn, make the pain more difficult to manage. Likewise, psychological ailments can have physical implications that lead to chronic pain. Back pain, for example, is more common among people with anxiety and mood disorders, according to the Anxiety and Depression Association of America.
Rather than aiming to mask or eliminate chronic pain, this treatment type, which includes CBT, works by reconfiguring thought patterns.
"The prefrontal region and limbic system are associated with affective aspects of pain and regulate emotional and motivational responses," said Mairead Molloy, relationship psychologist. "These brain regions are not activated separately; they are functionally connected and contribute in a combined fashion to pain processing. Therefore, when a person is suffering from chronic pain, it can affect every aspect of his or her life."
Somia Zaman, a psychotherapist specializing in CBT and EMDR, elaborated on this point.
"People with chronic pain often suffer from depression and/or anxiety, and this is understandable considering the massive impact in other areas of life pain can have," Zaman said. "It's common for people with pain to isolate themselves and reduce activities or hobbies, and this can make people vulnerable to depression or low self-esteem. Anxiety can also feature in pain as people can become anxious or worried about their future and their quality of life."
Zaman added that people with pain often reduce their activity level to avoid exacerbating the condition but this plan typically backfires and worsens the pain and mental health.
Experts previously associated centralized pain with nerve injuries almost exclusively. However, today's health professionals know it relates to various conditions, including arthritis, fibromyalgia, chronic low back pain, irritable bowel syndrome (IBS), chronic headaches, chronic post-surgical pain, chronic fatigue syndrome and endometriosis pain.
This knowledge has prompted what's known as the "biopsychosocial pain management" movement, a term encompassing treatments that address situations, beliefs, expectations and emotions that shape a person's pain perception. Rather than aiming to mask or eliminate chronic pain, this treatment type, which includes CBT, works by reconfiguring thought patterns.
What is CBT?
Cognitive behavioral therapy (CBT) is a form of talk therapy designed to help patients identify and change problematic thought and behavioral patterns. According to the American Psychological Association (APA), it effectively treats various conditions, including depression, anxiety, eating disorders, substance use disorders and chronic pain. Per the APA, "Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life," and cognitive behavioral therapy can be as or more effective than other psychiatric treatments, including medication.
As the APA explains, CBT is based on a few core principles, including the notion that psychological challenges can stem, in part, from faulty or unproductive ways of thinking and learned patterns of unhelpful behavior.
"It focuses on the ways our thoughts, feelings, and behaviors impact each other to either keep us from or help us to live the lives we want," said Bruce F. Singer, Psy.D. "Distortions of thought, such as fortune-telling, mind-reading, or black and white thinking—which all of us engage in from time to time—can lead to catastrophized emotions and unhealthy behaviors. CBT asks us to examine the 'evidence,' or lack thereof, for unhealthy ways of thinking, and asks us to replace those thoughts with alternative, or more balanced, [thoughts] that, in turn, lead to new sets of emotions and actions."
How it works for chronic pain
Perceiving pain and its associated risks as more severe than they are is known as pain catastrophizing. When this happens, Zaman said pain can become all-encompassing, leading to self-limiting thoughts and behaviors to avoid worse suffering.
"The reason people may come to believe this is because they may have had a bad experience one time when they overexerted themselves, causing more pain," Zaman said. "This can then be generalized or catastrophized to every situation, leaving people unwilling to take any risks in case their pain peaks again."
Zaman added that the emotional and social effects of physical pain, which tend to worsen the condition, contribute to pain catastrophizing.
"Pain catastrophizing is why an individual might describe their pain level as 15/10 even when the pain level charts stop at 10/10," he said. "Rather than dismiss an individual's experience as exaggeration, our job as pain therapists is to empathize with their perspective while facilitating the skills they need to cope with and manage the big emotions of anger, fear, loss, sadness and shame that make up the suffering component of physical pain."
"Take the phrase, 'My back is killing me,' which so many individuals use automatically to describe their chronic pain," Singer said. "As a CBT therapist, I challenge this thought because it leads to self-victimization and despair. Many people have told me it is just a figure of speech, to which I reply, 'Yes, but it is one you use habitually a dozen times a day, and now you've come to believe it and have lost all hope.' Working together, we might substitute the thought, 'I have intense pain right now.' This acknowledges the truth of one's condition but allows room for hope. Maybe the pain won't be so intense in an hour or a day or a week."
Identifying unproductive thought patterns and behaviors, and replacing catastrophic or irrational thoughts with more rational, realistic ones are just one facet of CBT's potential. Research indicates, by diminishing chronic stress, techniques like cognitive behavioral therapy may alter neurochemical makeup and improve the body's natural pain relief response.
According to Singer, while effective, CBT has its limitations. To compensate for these, complementary practices and therapies, including mindfulness and acceptance commitment therapy (ACT), can be helpful. Additionally, cognitive behavioral therapy is typically used in conjunction with other techniques, including physical therapy, massage, medication and lifestyle changes.
"These modalities ask us to change our relationship to the thoughts we can't change through the practices of self-compassion, gratefulness and self-acceptance," Singer said. "Living mindfully with a chronic condition means seeing yourself as whole rather than broken. It asks us to commit to our values or what matters most to us not just despite the pain but because of it. We begin to focus less on what is wrong with us and more on what is not wrong with us."