Goal setting is an integral part of CBT-CP. Setting well-developed, individualized goals helps patients engage in treatment and providers tailor pain care plans and interventions. Goals should be specific and behavioral and avoid vagueness or focusing on pain score reductions. Although reductions in pain scores can be a by-product of CBT-CP, the primary objectives in CBT-CP are to increase pain self-management skills and to improve functioning and quality of life. Pain scores are not always reliable or accurate measures of functioning on their own. When setting goals, it is helpful to use the SMART goal model²¹:

S—Specific

M—Measurable

A—Achievable

R—Relevant and personally meaningful

T—Time bound

Providers can elicit SMART goals by asking questions such as, “How do you know if you are meeting your goal?” “What would that look like?” “What would you like to get back to or be doing more of if your pain were better managed?” An example of a SMART goal is “I will walk for ten minutes every morning for the next two weeks.” As patients meet their goals, they build confidence in their abilities to engage in important activities and ultimately develop more substantial goals. If patients are unable to meet goals, it provides good clinical information that helps providers work with patients to problem-solve challenges and also adjust goals to reflect the patient’s current level of functioning.

The stress response is a sympathetic nervous system response comprising cognitive, emotional, and physiological components, colloquially referred to as “fight or flight.” Signs of the stress response are increased heart rate, shallow breathing, muscle tension, anxiety, and negative beliefs about a particular activity or situation. Chronic pain, as a chronic stressor, can result in a prolonged stress response.

Relaxation training engages the parasympathetic nervous system by targeting the physiological arousal of the stress response and working to calm the body. Relaxation techniques are a direct way to intervene and slow down or stop the stress response. There are several different types of relaxation techniques, with diaphragmatic breathing, progressive muscle relaxation, and guided imagery being the most commonly used for chronic pain. Relaxation techniques offer a direct and purposeful method for patients to experience their body and pain differently. This can be a very powerful experience for patients with chronic pain who hold the belief that they have no control over their bodies or pain. As patients become more adept at eliciting the relaxation response, they can decrease the frequency and intensity of the stress response and their reliance on passive pain management strategies.

Patients with chronic pain often experience frustration and distress over their reduced activity level over time. They may describe themselves as cycling through “good days and bad days” or an up and down cycle characterized by a perceived lack of control and inevitability of pain flares. The result is a profound negative impact on an individual’s confidence in their ability to engage in even the most basic of activities, such as preparing meals or completing chores at home. It often leads to avoidance of activities, increased social isolation, and a higher frequency of pain flares.

Among patients with chronic pain, a common pattern of activity is that individuals will ignore early pain signals and “push through” pain until it is too intense to continue or the activity is complete. This often triggers a pain flare, which can last from hours to days. As this pattern continues to occur, the brain lowers the pain threshold for the activity in an effort to reduce the frequency of flares and stress on the body. Over time, this increased pain sensitivity results in lower amounts of activity, triggering more intense flares and a subsequent overall lower level of general activity.

Time-based pacing involves taking a thoughtful approach to activities and working “smarter not harder” by alternating periods of activity with breaks.²¹
Individuals create a baseline activity level calculated by identifying how long an activity takes before significant pain, and reduce that time by 20%. For example, if an individual identifies that 10 minutes of walking results in a flare, then they would walk for 8 minutes, take a break, and walk again for 8 minutes, and so on. The goal is to stay below the pain threshold. Between periods of activity, patients are asked to take breaks and engage in relaxing activities that calm the body and lower the stress response. Over time, as individuals are able to engage in more activities with a lower frequency of flares, they become less sensitive to pain. As their pain thresholds increase, periods of rest decrease and we see an overall upward trend in activity level.

Identifying and challenging negative cognitions is a powerful intervention for patients with chronic pain. Negative cognitions are associated with disability, pain intensity, depression, interference with daily activities, and beliefs about one’s ability to cope with pain.^16,22,23,24 Cognitions play an important role in motivation to engage and exert effort in treatment and perception of treatment efficacy. For example, pain catastrophizing, defined as ruminating about worst-case scenarios, has been associated with poorer physical and psychological outcomes, even when controlling for pain.¹³ Although it is known that chronic pain is not simply “in the head,” the beliefs that we hold about our pain and ability to cope have a significant impact on pain experience and treatment outcomes.

Cognitive restructuring is a multistep process, with the first being the identification of negative thoughts. Negative emotions often serve as reliable cues for finding such cognitions. Once the thought is identified, the second step is to explore and challenge the thought by examining facts and looking for alternative perspectives. When challenging beliefs, it is helpful to ask several different questions to better assess the accuracy and validity of the belief, such as “Is this 100% accurate?” “Is there any evidence to contradict this thought?” “Is this thought helpful or harmful to me?” The last step is to generate an alternative, or more balanced, thought. Alternative thoughts should be realistic and unbiased, offering an accurate and healthy perspective on how one interprets experiences.

Pain flares are defined as times pain increases from its average intensity level to a higher level and remains at that higher level for a prolonged period of time (ranging from hours to weeks). Pain flares are a common phenomenon in chronic pain, and although many patients with pain can significantly decrease the frequency of flares through a variety of behavioral techniques, pain flares can still occur periodically. Planning ahead is essential when it comes to managing pain flares. Flare plans should utilize a variety of coping strategies from multiple categories. These may include relaxation techniques, coping statements, distraction activities, ice or heat therapies, and gentle stretches. The purpose of the plan is to provide the patient with a variety of coping strategies for sustaining through the flare in a safe manner without inadvertently prolonging it. For many patients with pain, it is difficult to generate a plan in the midst of a flare. Preparing a flare plan builds confidence within the patient that they have the skills necessary to address a flare should it arise. Moreover, a flare plan can reduce reliance on maladaptive behaviors, such as dangerously escalating usage of opioid pain medications or using illicit drugs or alcohol to address a severe increase in pain intensity.