The most extensively studied psychological treatments for chronic pain come from the broad spectrum of operant-behavioural, respondent-behavioural and cognitive methods. These are normally used in combination (Turk et al. 1983), so reference is typically made to cognitive behavioural therapy (CBT) methods (e.g. Eccleston et al. 2013). Within the framework of CBT treatments, clinicians and researchers typically employ multiple components depending upon the population being treated. These can include increments in activities of daily life (walking, driving, shopping, cooking, etc.), regular exercising (stretch, strengthening, fitness), medication withdrawal, self-regulation strategies (relaxation, meditation, mindfulness), cognitive strategies (identifying unhelpful ways of thinking and changing them, distraction techniques, problem-solving), communication skills training, self-reinforcement, self-monitoring and so on.

The primary distinguishing characteristic of CBT approaches is that the learning or behaviour change principles informing CBT are utilised through all (or most) facets or components, such as exercises, activity upgrading, reducing medication, dealing with flare-ups in pain, sleep problems, etc. (see Nicholas and George 2011; Williams et al. 1999). As mentioned earlier, CBT for pain is also heavily reliant on models of pain that emphasise interactive relationships between the experience of pain, thought processes, mood, behaviours and their environmental contexts or contingencies (see Turk et al. 1983, for an early outline of this perspective). In recent years, these interactive relationships have been conceptualised in terms of moderators and mediators (Vlaeyen and Morley 2005). In this perspective, unhelpful beliefs about pain, for example, are thought to mediate the relationship between pain and effects like depression or disability. Accordingly, the psychological treatment is targeted at changing the unhelpful beliefs. In practice, the principles of operant and respondent learning (conditioning) are employed alongside cognitive methods aimed at processes like thoughts, worries, reactions, beliefs and expectations. The nature and emphasis of psychological approaches to chronic pain have evolved since Fordyce’s (1976) seminal work based on operant methods, but most continue to reflect this history. Most recently, what have been described as ‘third-wave’ versions of CBT, particularly acceptance and commitment therapy (ACT) (e.g. McCracken and Vowles 2014) have been promoted, but despite the input from relational-frame theory (Hayes 2004), these approaches still reflect their fundamental origins in learning principles (Vlaeyen 2014). Accordingly, rather than a completely new approach, this chapter will consider ACT-based approaches as lying within the framework of the broader CBT ‘family’.

Operant methods (Fordyce 1976) emphasise a focus on the graded performance (activity pacing) of agreed (and clearly specified) activities (towards goals desired by the patient) that are reinforced (by therapists and patients), contingency management (e.g. undesirable behaviours, like excessive resting, are not reinforced where possible), the use of modelling (demonstration of new skills or adaptive behaviours), rehearsal (of these behaviours), feedback (from therapists and self-monitoring) and structured plans (usually time limited), as well as application of specific self-management skills in normal life contexts (i.e. not just at clinic). For example, a patient might be taught a relaxation technique, and their practice of this would be reinforced by the patient charting his/her practice and by the therapist verbally (see Nicholas and George 2011).

Respondent methods emphasise repeated exposure to cues or indicators for increased pain or avoidance of activities expected to be painful (e.g. de Jong et al. 2005). Thus, the patient is encouraged to repeatedly perform a previously avoided behaviour (such as lifting an object of a certain weight) until the patient is able to perform the activity without distress.

Cognitive methods typically include self-monitoring of thoughts and emotions to gain awareness of their relationships (e.g. whether certain ways of thinking might mediate the relationship between pain and distress). Once these unhelpful thoughts or patterns of thinking, such as catastrophic beliefs (e.g. ‘this pain is killing me’), are identified, the treatment involves helping the patient work out more helpful alternatives and then applying them as needed. Some semi-structured methods for dealing with setbacks or obstacles (problem-solving) are often included as well (Van den Hout et al. 2003).

Exponents of ACT-based methods typically use different terms to describe this approach, but fundamentally they target experiential avoidance using exposure methods as well as recognising unhelpful or self-defeating thoughts that are challenged indirectly by the use of metaphors and disengagement. In these respects, these approaches are analogous to respondent-behavioural and cognitive therapy approaches.

In practice, elements of all three methods are often employed in an integrated manner. Thus, while a patient is engaging in a specific behaviour that she/he may have previously avoided due to worries about pain, she/he can reinforce the attempt by recording it in a diary (i.e. subsequently acknowledged by the clinician) and simultaneously the patient can also be dealing with any unhelpful thoughts using the cognitive therapy strategies. The fundamental goal of CBT for chronic pain is to enable treated patients to lead their lives with as little interference due to pain as possible. This means that they must employ effective pain self-management strategies to combat the experience of pain on their daily lives. From a CBT perspective, these treatments entail the strengthening of new, more helpful behaviours and the weakening of older, less helpful behaviours.

Two main lines of evidence are available – one refers to treatment programs that include multiple components and disciplines and the other refers to specific modalities that may be used in isolation, like relaxation, biofeedback or behavioural exposure by single practitioners.