Chronic pain is a significant public health concern globally with ever increasing prevalence rates and costs.1
In the United States alone, at least 116 million people are affected by chronic pain at a cost of 560 to 635 billion dollars annually owing to direct medical care, higher rates of health care utilization, and lost productivity.1
In addition, chronic pain is associated with decreased quality of life2
and increased rates of depression.3,4,5,6
Chronic pain is complex, and understanding the cause and maintenance requires a shift from the biomedical model to the biopsychosocial model. In traditional biomedical models, mind and body are conceptualized as separate entities that function independently of one other. Historically, utilizing the dualistic model to guide treatment has proven to be inadequate across a wide range of medical disorders. This has been particularly true for chronic pain, where psychosocial factors such as emotional distress significantly impact symptom reporting and treatment response.7
The biopsychosocial model frames chronic pain as a complex output of biological factors, psychosocial factors, and environmental factors interacting in a dynamic and reciprocal fashion. Each of these factors contributes to the development, experience, and maintenance of pain and response to treatment.8,9
From the biopsychosocial perspective, ideal chronic pain treatment is multimodal, with treatment plans incorporating several interventions for chronic pain. Potential
interventions include but are not limited to pharmacology, manual therapies, procedural therapies, and psychological interventions. This chapter focuses on 2 widely used psychological interventions for chronic pain: cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT).
COGNITIVE BEHAVIORAL THERAPY FOR CHRONIC PAIN
CBT, adapted and studied to treat a wide range of problems (e.g., substance use disorders, insomnia, somatoform disorders, and mood disorders)10
across diverse populations, is based on the premise that cognitions cause and maintain negative emotional states and maladaptive behavioral patterns. More simply put, how individuals think influences how they feel and what they do in response. CBT is short term and goal oriented with the expectation that the patient is an active participant; the therapeutic relationship is marked by collaboration. CBT focuses on how maladaptive cognitive thinking styles (e.g., all or nothing thinking, mind reading, and overgeneralization) and behaviors manifest and the impact that these patterns have on current emotions and functioning. Interventions include goal setting, disputing distorted (or maladaptive) thoughts through Socratic questioning, and behavioral experiments in which individuals trial different coping strategies and record outcomes.
CBT for chronic pain, or CBT-CP, is one of the most widely used and empirically supported psychosocial interventions for chronic pain. CBT-CP incorporates the pain experience into the traditional CBT model: the way an individual thinks, feels, and acts influences pain, and pain in turn impacts thoughts, emotions, and behaviors.
Several meta-analyses have examined the efficacy of CBT for a multitude of chronic pain conditions, including chronic low back pain,11
arthritis, and orofacial pain.13
The consensus across these studies is that CBT is
an efficacious treatment of a multitude of chronic pain conditions. CBT for chronic pain has demonstrated “positive effects” on pain intensity, quality of life, depression, and physical functioning when compared with treatment as usual (TAU) or waitlist.11
Williams, Eccleston, and Morely14
completed a systematic review comparing CBT with both other
behavioral treatments and TAU for chronic pain. When compared with behavioral treatments (defined as “treatments that are purely behavioural technologies such as biofeedback”) and TAU, CBT demonstrated small to moderate significant
improvements in pain intensity, disability, mood, and catastrophizing.14
From a biopsychosocial perspective, the most robust treatment would be multimodal, with simultaneous interventions targeting different areas of functioning. For example, one would expect that CBT in addition to physical therapy and pharmacotherapy would result in better outcomes than any intervention alone.15
The treatment focus in CBT-CP is on improving self-efficacy, increasing functioning, and improving overall quality of life. Note that identifying the cause of a patient’s pain and finding a “cure” or “fix” for chronic pain are not focal points in treatment, although many report a decrease in pain scores. This is an important distinction for several reasons. The first is that this approach promotes an internal locus of control versus external locus of control (i.e., “Only surgery can help me”). Second, it reinforces active coping and self-management strategies. Third, this approach promotes improvement on measurable, functional goals rather than subjective pain scores. Last, this approach promotes self-efficacy and a focus on how to live life in a valued and functional way.16
A primary goal in CBT-CP is the development and strengthening of active coping for pain, which is defined as managing pain through one’s own resources. Examples of active coping include exercise, use of relaxation techniques, and increasing engagement in valued activities. Many patients with chronic pain seen in medical settings engage in passive coping, defined as managing pain through a reliance on external factors and/or behaviors that reflect perceived helplessness.17
Passive coping includes guarding, excessive rest, activity avoidance, and use of pain medications. Reliance solely on passive coping strategies is associated with higher rates of disability, increased pain, and greater medication utilization.18,19,20
Active coping, on the other hand, is associated with decreased disability19
and higher self-efficacy beliefs.17
Utilizing active strategies can disrupt the passive pain coping cycle often seen in patients with chronic pain. A comprehensive chronic pain care plan includes both passive and active coping strategies.