Psychotherapy and Cognitive-Behavioral Therapy

Psychotherapy and Cognitive-Behavioral Therapy

Jessica W. Guite

Michael Reiss


With the advent of the biopsychosocial model of pain (Engel, 1977), there is a greater appreciation of the role that factors such as emotion, cognition, and social interaction can play in the experience of pain. Because pain is defined as a “mutually recognizable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity” (Cohen, Quintner, & van Rysewyk, 2018), it is also amenable to interventions that impact these factors. The majority of psychotherapy research focusing on chronic pain has examined cognitive-behavioral therapy (CBT). CBT was originally developed by Aaron Beck, MD in the 1960s (Beck, 1963) to treat depression, and it differed from other psychotherapies (e.g., psychodynamic and behavioral) of the time (Strupp & Binder, 1984; Wolpe, 1973). CBT emphasizes the modification of dysfunctional thinking in order to bring about lasting emotional and behavioral change (Beck, 2011; Beck, Rush, Shaw, & Emery, 1979). It is a model-driven approach that is structured, can be readily taught, can be empirically assessed, and has an emphasis on solving present problems within a relatively short period of time and therapeutic contacts.

More recent developments, referred to as the “third wave” of CBT, include interventions such as acceptance and commitment therapy (ACT), dialectic behavior therapy, functional analytic psychotherapy, mindfulness-based cognitive therapy, and other acceptance- and mindfulness-based approaches. Of these, ACT has been among the most frequently used for patients with chronic pain. ACT was developed by Steven Hayes, PhD and incorporates acceptance and mindfulness strategies to change a person’s relationship with and perspective on psychological events in order to gain psychological flexibility and engage in committed action (Hayes, Pistorello, & Levin, 2012; Hayes, Strosahl, & Wilson, 1999). Both CBT and ACT have been adapted for use with patients with chronic pain, with research to support the efficacy of psychotherapeutic interventions for patients coping with chronic pain conditions throughout development.

Evidence for Psychotherapy Interventions for Chronic Pain

The critically important role of psychosocial factors within biopsychosocial approaches to treatment is well supported by evidence for the benefits of psychotherapy to treat children, adolescents, and adults with chronic pain. We provide a brief review of the evidence base for psychotherapy to treat children and adolescents with chronic pain followed by research with adults with chronic pain.

Children and Adolescents

There has been recent evidence supporting the use of psychotherapy to treat chronic pain in children and adolescents. Eccleston et al.’s (2014) systematic review of 37 randomized controlled trials for the management of chronic and recurrent pain in children and adolescents found that psychological treatments tended to be behavioral or cognitive behavioral. The majority of research in Eccleston et al.’s review has been done on youth with headaches (n = 20/37). This review found that psychological treatment was effective in reducing pain intensity and disability in children with chronic headache with lasting effects, although the sample size was small. For children and adolescents with other chronic pain conditions besides headache (n = 17/37 studies), there is evidence to support reduced pain outcomes immediately posttreatment (but not evidence to support maintenance of gains at follow-up for those with mixed pain [i.e., both headache and nonheadache pain]). Results of this systematic review of available research also provide evidence for the effectiveness of relaxation and CBT for reducing pain intensity in children with headache, abdominal pain, fibromyalgia, and sickle cell disease when assessed immediately posttreatment. It was concluded that 56% of children treated with psychological therapies reported less pain, compared to 22% of children not receiving therapy. A related meta-analysis closely examined the benefits of psychotherapy and explored optimal dose of treatment for pediatric chronic pain conditions including headache, abdominal, musculoskeletal, and neuropathic pain (Fisher et al., 2014). Results examined outcomes for pain, disability, depression, anxiety, and sleep. Psychotherapy for headache pain improved symptoms significantly at posttreatment and at follow-up, with higher treatment dose leading to greater reductions in pain. For abdominal pain, significant improvements in pain and disability were found, whereas children experiencing musculoskeletal pain had significantly reduced pain, disability, and depression posttreatment, which was sustained for disability at follow-up.


There is similar evidence to support the efficacy of psychotherapy treatment for adults with chronic pain. Williams, Eccleston, and Morley (2012) examined 35 randomized controlled trials comparing psychological therapy (CBT and behavior therapy) with control conditions (either waitlist or treatment as usual). They found that CBT had small positive effects on disability and catastrophizing, but not on pain or mood, in comparison to control conditions. Pain, disability, mood, and catastrophizing improved immediately posttreatment compared to controls, with a small effect for improvement in mood maintained at follow-up. The authors noted that there is
an absence of evidence for behavioral therapy, which tends to be focused solely on increasing desirable behaviors, with less focus on thoughts and feelings (Wolpe, 1973). Bernardy, Klose, Busch, Choy, and Häuser’s (2013) systematic review found similar benefits of treating fibromyalgia with CBT. Specifically, they found that CBT slightly reduces pain, negative mood, and disability in children, adolescents, and adults immediately after treatment and at 6-month follow-up. Although there is widespread support for the benefits of CBT for many chronic pain conditions, Eccleston, Hearn, and Williams’ (2015) review of psychological treatment for chronic neuropathic pain in adults did not find clear benefit of psychological treatment for all neuropathic conditions (e.g., spinal cord injury and burning mouth syndrome).

The literature also shows evidence for beneficial effects of treating adult chronic pain with ACT. Hughes, Clark, Colclough, Dale, and McMillan (2017) examined 11 randomized controlled trials comparing ACT to a control condition, active treatment, or waitlist/active treatment. They found significant, medium to large effect sizes for outcomes including pain acceptance and psychological flexibility. Small to medium effect sizes were found for outcomes including improved physical functioning, anxiety, and depression; however, no significant effects were found for quality of life and pain intensity. Stability of these findings at follow-up tended to show smaller effect sizes. It is important to interpret these findings in the context of the current limited number of trials examining ACT or that compare ACT to other active treatments. Although ACT treatments presently show promising short-term initial improvement for outcomes, the stability of these findings over time is diminished.

Chronic Pain and Associated Mental Health Concerns

Many patients with chronic pain experience pain-related anxiety, also termed pain “catastrophizing,” which has been described as “an exaggerated negative orientation toward noxious stimuli” (Sullivan, Bishop, & Pivik, 1995, p. 524). Tunks, Crook, and Weir’s (2008) overview of the epidemiology of chronic pain illustrates how chronic pain significantly predicts new onset of depression and that
depression significantly predicts the onset of chronic pain among adult samples. Similarly, among a nationally representative cohort of adolescents, Tegethoff, Belardi, Stalujanis, and Meinlschmidt (2015) found approximately 25% of the sample experienced chronic pain and mental disorder in their lifetime on the World Health Organization Composite International Diagnostic Interview Version 3.0 (World Health Organization, 2018). The co-occurrence of chronic pain and mental disorders for teenagers ranged from 1.91% for presence of any eating disorder to 17.40% for presence of any anxiety disorder. The authors found that anxiety, affective, and behavior disorders may be risk factors for chronic pain.

In addition to these mental disorders associated with chronic pain, there is growing consensus of a relationship with adverse childhood experiences (ACEs) (e.g., physical abuse, sexual abuse, early parental loss). ACEs may alter the hypothalamus-pituitary-adrenal axis, in turn putting an exposed individual at risk for mental disorder and pain-related issues (Felitti et al., 1998). Sachs-Ericsson, Sheffler, Stanley, Piazza, and Preacher’s (2017) longitudinal study found that verbal and sexual abuse, early parental loss, and parent psychopathology were associated with painful medical issues. Nelson, Simons, and Logan (2018) found that 82% of youth with chronic pain report at least one ACE in their lifetime, with almost one-fourth having three or more ACEs, and that ACE exposure was significantly associated with psychological distress (e.g., anxiety, depression). Salazar et al.’s (2013) retrospective cohort study of over 1000 adults in primary care with musculoskeletal pain found a high level of undiagnosed mood disorders, with female gender, high pain intensity, and sleep disruption because of pain contributing to this diagnosis. Apart from distinct mental illness, chronic pain inevitably raises levels of stress, which tends to exacerbate pain levels. One cannot underestimate the contribution of psychological factors to a patient’s experience with chronic pain.

When to Refer a Patient with Chronic Pain to Therapy

When a patient experiences pain for 3 months or longer, functional limitations that were not present before the onset of pain are more likely to occur (Bursch, Walco, & Zeltzer, 1998). This section reviews functional limitations that are common to people experiencing chronic pain. In addition, we will consider the value of referring a patient with chronic pain and disability for psychological intervention to facilitate increasing engagement in treatment recommendations (e.g., physical therapy adherence) or address psychosocial factors that serve to impede engagement in functional activities.

Children and Adolescents

When a child or adolescent experiences chronic pain, school performance, peer relationships, sleep, family functioning, and physical activity are often disrupted (Palermo, 2012). As noted earlier, trauma (i.e., ACEs) and pain can be highly comorbid, which can further contribute to disability and ripple effects that radiate across systems of support (Guite, Logan, Ely, & Weisman, 2012). For example, children and
adolescents may experience declining school attendance and associated declining grades. Chronic pain may also interfere with peer relationships, especially if the child is not attending school and is isolated from others. Sleep may also be disrupted because of chronic pain. It is important to note that sleep and chronic pain have been shown to have a bidirectional relationship (McCracken & Iverson, 2002) and that complex patterns of parent-child interactions have also been implicated in the associations among sleep, pain, and disability (Puzino, Guite, Moore, Lewen, & Williamson, 2017). Chronic pain affects not just the individual, but the family as well (Jordan, Eccleston, & Osborn, 2007; Palermo & Chambers, 2005). Relationships are prone to change as caregivers can check in more with a child or adolescent giving way to an enmeshed relational style, which may further set the child back. Parent caregivers may respond differently to a child or adolescent’s pain, which may create further familial conflict. Finally, physical activity limited by chronic pain can disengage children and adolescents from participating in previously pleasurable activities, which may also impact the social domain.

The Functional Disability Inventory (Walker & Greene, 1991) is a valid and reliable instrument for children 8 to 18 years of age with chronic or recurrent pain that can be of help to understand a child’s current functioning and limitations across several domains as well as provide a window into the response to treatment over time. Measures such as the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) (Cella et al., 2007; Kashikar-Zuck, Carle, et al., 2016), as well as multiple other brief, validated measures are freely available to facilitate assessment for both children and adults seen in clinical settings (Beidas et al., 2015). Consensus recommendations for selection of outcome measures for clinical trials focusing on pediatric chronic pain have also been provided (McGrath et al., 2008).


Functional disability for adults with chronic pain has many similarities to children with respect to physical and social domains. Whereas youth with chronic pain often experience disruption in school attendance (i.e., their primary vocation/responsibility), chronic pain for adults can significantly impact an adult’s occupational functioning (Gatchel, 2004), such as the ability to work inside or outside the home. This may impact earning potential (Anagnostis, Gatchel, & Mayer, 2004) and can place added strain on relationships with significant others, especially if they are interdependent on others (e.g., spouses) for financial and emotional support. Deficits in activities of daily living (e.g., grasping for objects and personal care) may be pronounced for adults with chronic pain. The NIH PROMIS (Cella et al., 2007) provides brief, validated measures for the assessment of pain, disability, and various emotional factors frequently co-occurring with chronic pain. Various other specialized legacy measures have been developed and validated within specific chronic pain populations, with consensus recommendations for selection of outcome measures for clinical trials also provided (Dworkin et al., 2005; Turk et al., 2006).

Prerequisite Skills Needed to Refer and Apply CBT

Providers are encouraged to discuss the potential for referral for behavioral health support for patients with chronic pain at the first care contact. The importance of setting the stage for clear and open communication about the benefits of behavioral health support and evidence for CBT efficacy in the treatment of chronic pain cannot be understated (Guite et al., 2012, 2014). Commitment to a biopsychosocial approach to pain management that dispels mind-body dualistic thinking aids providers in taking an educational stance with their patients about the important role that CBT can play in a pain coping toolkit. Providers need to appreciate that patients and families often may be reluctant to initially raise questions about this treatment modality because of concerns about stigma or worry that providers do not believe the pain is “real” and won’t help them unless there is a “biologic” underpinning for the pain symptoms. Having established open communication about the important role that behavioral health plays in pain coping early on, making a referral for these services when indicated becomes quite smooth and straightforward. The emphasis of this section is twofold: suggestions for how to initiate and complete a successful psychological referral and how to set the stage for a patient/family to successfully engage in treatment.

Understanding the Patient Perception of Pain and Psychotherapy

A patient who has exhibited pain for 3 months or longer has likely been to several different medical providers and may have come away (or been told) in the process that there is little direct medical explanation for their pain and that the pain is all “in their head.” Patients tend to internalize such experiences from prior visits, which can directly impact present care. Patients may have a negative view of the medical care and associated psychological recommendations they have received prior to the visit. Before referring a patient with chronic pain for therapy, one must be careful to listen to and validate patient experiences. What have other providers told them about their pain and how can therapy be beneficial? It is not uncommon for individuals with chronic pain to exhibit stigma in the medical setting, especially because chronic pain is often invisible to others and complex in nature (Collier, 2018).

The Therapeutic Alliance

The therapeutic alliance is the bedrock in the relationship between the patient and the provider and has been described as representing mutual collaboration and partnership between the patient and the therapist (Horvath, Del Re, Flückiger, & Symonds, 2011). Rogers’ (1957) seminal paper describes that the necessary and sufficient conditions of therapeutic personality change that transcends strictly “psychotherapeutic” relationships include empathy (sensing the client’s world as one’s own), congruence (genuineness), and unconditional positive regard
(warmly accepting the patient). Horvath et al.’s (2011) meta-analysis found a moderate and highly reliable association between alliance and psychotherapeutic outcome. More recently, Welmers-van de Poll et al.’s (2018) meta-analysis of alliance in treatment outcome of youth participating in family involved treatment found that quality of alliance was significantly associated with treatment outcome.

Active Listening

Active listening is one way to engage the patient in order to foster and build the therapeutic alliance. It requires the provider to listen for total meaning both in content and feeling through acknowledgment of the patient’s experience (Rogers & Farson, 1987). Just by listening, a provider can ensure that the patient feels heard and conveys that one cares about the patient and demonstrates respect for them. This is especially important for patients with chronic pain who may have been followed by multiple providers with varying levels of alliance with each provider. How does a patient know that you are listening? Exhibiting nonverbal signals such as nodding and making eye contact can be helpful in this regard. Verbally, the clinician can reflect or rephrase what they hear from the patient to ensure they are understanding what the patient is saying. Active listening and reflection can lead to an enhanced therapeutic alliance and a greater shared understanding between the patient and clinician and provide critically important opportunities for providers to dispel misunderstandings or misconceptions that may otherwise sabotage desired treatment goals. With the advent of the electronic health record, the clinician needs to balance not only attention to documentation but also attention to the patient to ensure optimal engagement (Sulmasy, López, Horwitch, American College of Physicians Ethics, & Professionalism Human Rights Committee, 2017).

Motivational Interviewing and Establishing a Patient’s Readiness to Change

Miller and Rollnick (2012) developed and created motivational interviewing (MI) in order to decrease ambivalence related to behavior change via strengthening a patient’s motivation to change. Alperstein and Sharpe’s (2016) meta-analysis to better understand the efficacy of MI in adults experiencing chronic pain found that MI can increase short-term adherence to treatment for chronic pain but did not show gains in physical function compared to controls. Patients with chronic pain may have some ambivalence about modifying their lifestyle in order to manage their pain. Eliciting the pros and cons of making versus not making changes can help the clinician understand the patient’s ambivalence and increase motivation to change. Most of the literature for MI and chronic pain focuses on adults. Chilton, Pires-Yfantouda, and Wylie’s (2012) systematic review of utilization of MI within musculoskeletal health showed no studies contained children. More recently, the pediatric literature has started to focus on use of MI for chronic health conditions such as diabetes (Stanger
et al., 2013), though studies reporting on this within pediatric chronic pain populations were not identified. Providers are advised to not underestimate the importance of eliciting feedback in order to ensure a shared understanding with patients and families around intent to engage in treatment and to resolve ambivalence regarding pursuing a recommended treatment.

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Apr 16, 2020 | Posted by in NURSING | Comments Off on Psychotherapy and Cognitive-Behavioral Therapy
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