Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach

From the WebMD Archives

Your body is aching and the pain feels unbearable. The last thing you want to hear is, “it’s all in your head.” For people with chronic pain, the discomfort is very real, and they know all too well they feel it in their bodies.

“If you are lying in bed and hurting, the pain is your whole world,” says Joseph Hullett, MD, board certified psychiatrist and senior medical director for OptumHealth Behavioral Solutions in Golden Valley, Minn.

Enter cognitive behavioral therapy as a method of pain management.

Cognitive behavioral therapy (CBT) is a form of talk therapy that helps people identify and develop skills to change negative thoughts and behaviors. CBT says that individuals -- not outside situations and events -- create their own experiences, pain included. And by changing their negative thoughts and behaviors, people can change their awareness of pain and develop better coping skills, even if the actual level of pain stays the same.

“The perception of pain is in your brain, so you can affect physical pain by addressing thoughts and behaviors that fuel it,” Hullett tells WebMD.

What can CBT do for you? Cognitive behavioral therapy helps provide pain relief in a few ways. First, it changes the way people view their pain. “CBT can change the thoughts, emotions, and behaviors related to pain, improve coping strategies, and put the discomfort in a better context,” Hullett says. You recognize that the pain interferes less with your quality of life, and therefore you can function better.

CBT can also change the physical response in the brain that makes pain worse. Pain causes stress, and stress affects pain control chemicals in the brain, such as norepinephrine and serotonin, Hullett says. “CBT reduces the arousal that impacts these chemicals,” he says. This, in effect, may make the body’s natural pain relief response more powerful.

To treat chronic pain, CBT is most often used together with other methods of pain management. These remedies may include medications, physical therapy, weight loss, massage, or in extreme cases, surgery. But among these various methods of pain control, CBT is often one of the most effective.
“In control group studies, CBT is almost always as least as good as or better than other treatments,” Hullett says. Plus, CBT has far fewer risks and side effects than medications or surgery.

To help provide pain relief, cognitive behavioral therapy:

  • Encourages a problem-solving attitude. “The worst thing about chronic pain is the sense of learned helplessness -- ‘there is nothing I can do about this pain,’” Hullett says. If you take action against the pain (no matter what that action is), you will feel more in control and able to impact the situation,” he says.
  • Involves homework. “CBT always includes homework assignments,” Hullett says. “These may involve keeping track of the thoughts and feelings associated with your pain throughout the day in a journal, for example. “Assignments are then reviewed in each session and used to plan new homework for the following week.”
  • Fosters life skills. CBT is skills training. “It gives patients coping mechanisms they can use in everything they do,” Hullet says. You can use the tactics you learn for pain control to help with other problems you may encounter in the future, such as stress, depression, or anxiety.
  • Allows you to do it yourself. Unfortunately, good qualified cognitive behavioral therapists aren’t available in all areas. Luckily, you can conduct CBT on your own as a method of pain control, even if you’ve never set foot in a therapist’s office. “CBT is a cookbook approach. It can easily be applied to self-help and computerized programs,” Hullett says. And the literature supports that these self-help methods can be just as effective for pain management as one-on-one sessions.

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What You Can Expect

If you want to try CBT for pain management, first talk with your doctor. He or she may know of a cognitive behavioral therapist who specializes in chronic pain or be able to point you in the right direction.

Most cognitive behavioral therapy for pain control consists of weekly group or individual sessions lasting 45 minutes to two hours. Expect to attend between eight and 24 sessions, with possible “booster” sessions to refresh your skills.

“When you begin, the therapist will evaluate your pain, including the history and your current pain management methods,” says Katherine Muller, PsyD, director of the cognitive behavioral therapy program at Albert Einstein College of Medicine in New York City.

Your doctor will also do a general psychological assessment to identify any issues that may be making the pain worse. “The therapist will then work with you to design a specific treatment plan,” Muller says.

Muller notes that CBT is usually covered by insurance. “However, in some cases, insurance companies won’t cover the treatment unless it is for pain AND a psychiatric diagnosis,” she says. Check with your insurance company about your individual coverage.

Finding a CBT Therapist

Cognitive behavioral therapy is an increasingly popular treatment for all kinds of problems, pain relief included. As a result, more and more professionals call themselves cognitive behavioral therapists these days, even when they don’t have the proper training. To find a legitimate cognitive behavioral therapist who can help with pain management, do the following:

  • Check for credentials. “CBT is a very specific technical skill taught in certification programs,” Hullett says. “So inquire about training so you can be confident the therapist knows what he or she is doing.”
  • Conduct an interview. “Ask the therapist to tell you about his or her approach to treatment,” Muller says. “And consider setting up an evaluation visit to see how comfortable you feel talking with him or her.”
  • Choose someone you like. “In studies of psychotherapy, the number one determinant of outcome is whether or not the patient likes his or her therapist,” Hullett says. So now matter how much you respect a therapist as a professional, if you don’t like him or her personally, find someone else.

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How to Get the Most from CBT

To maximize the pain control power of CBT, do the following:

  • Believe it will work. Some people who try CBT proceed with caution because they worry that health care providers won’t believe the pain is real. “If you don’t feel listened to, you won’t engage in the process and do well,” Hullett says. Realize that your physician knows your pain is real and is referring you for CBT because it can help.
  • Actively participate. Like many things, you will get out of CBT what you put into it. “The more work you put toward completing your assignments and learning, the better your pain relief outcome will be,” he adds.
  • Complete the program. One issue with CBT is that people don’t always complete all aspects of the recommended program. “For the therapy to work for pain management, you have to attend sessions, do your homework, and follow the activity plan -- this is critically important,” Hullett says.
  • Practice new skills. “Practice the new ways you learn to think and act in response to pain often, even when you’re not in pain,” Muller says. This may also entail keeping a log of your pain and the skills you use to fight it. Practice will help you draw on your CBT skills automatically when you need them.
  • Keep an open mind. If you have a persistent need to be right or you can’t stand looking at things a different way, CBT won’t work for pain control. “You need to be able to see that there is an alternative way of looking at things that may be a better way and will help you,” Hullett says.
WebMD Feature Reviewed by Brunilda Nazario, MD on June 27, 2011

Sources

SOURCES: 

The Mayo Clinic: “Cognitive Behavioral Therapy.”

The National Association of Cognitive Behavioral Therapists: “Cognitive Behavioral Therapy.”

The University of Michigan Depression Center: “Cognitive Behavioral Therapy.”

Joseph Hullett, MD, board-certified psychiatrist and senior medical director, clinical strategy for OptumHealth Behavioral Solutions, Golden Valley, Minn.

Katherine Muller, PsyD, director, cognitive behavioral therapy program, Albert Einstein College of Medicine, New York City.

Glombiewski, J. Pain, Aug. 18, 2010.

Barsky, A. Seminars in Arthritis and Rheumatism, July 9, 2010.

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