More recent iterations of CBT for pain management incorporate the biopsychosocial conceptualization of pain [11]. This posits that pain is a complex experience that is influenced not only by its underlying pathophysiology, but also by an individual’s cognitions, affect, behavior, and sociocultural status. CBT aims to improve coping, self-efficacy, psychological and physical symptoms, and functional health [12]. Two principles in this approach are: (1) Problems with functioning related to pain can be addressed even if the pain is not targeted directly and remains unchanged and (2) Psychological factors can influence the experience of pain itself [8].

In CBT for pain, clinicians provide a treatment rationale that helps patients to better understand the role of cognitions and behavior in the pain experience and emphasizes the role that individuals play in managing their pain [13]. One underlying mechanism of treatment is changing the content of thoughts from maladaptive (e.g., catastrophizing) to adaptive thoughts that render one able to deal with situations effectively and to improve adjustment to the pain condition [14]. Another underlying mechanism of CBT is the use of more effective coping strategies to address the overwhelming stressor, chronic pain [14]. Coping skills training includes activity pacing and pleasant activity scheduling to help individuals maximize their daily functioning and quality of life [13]. Relaxation training is used to decrease muscle tension, to reduce psychological distress, and to divert attention away from pain. Individuals are also taught problem-solving methods that enable them to develop plans for dealing with pain exacerbations. As more effective coping strategies are consistently used, psychological distress will be reduced and functioning will be improved.

Several meta-analyses have demonstrated that cognitive behavioral therapy in the treatment of chronic pain and associated disability and psychological distress has been regarded as the most efficacious in terms of reduced pain and improved daily functioning [15–19]. Additionally, CBT for the treatment of chronic pain has been regarded as a cost-effective approach, especially when compared with commonly utilized medical approaches ([20, 21]).

Recently, specific developments in theory and methods have resulted in approaches in the wider field of CBT that regard suffering as inherent in the human condition, which is built into the design of human experience and behavior [8]. Within the framework of Contextual Cognitive Behavioral Therapy (CCBT; [22, 23]) are acceptance-based and mindfulness-based approaches [24]. These approaches emphasize experiential methods and changing responses to symptoms rather than to symptoms themselves.

Acceptance and Commitment Therapy (ACT; [25]) is a CCBT approach that includes a combination of acceptance and mindfulness methods along with activation and behavior change strategies. In addition, it emphasizes cognitive processes and emotional experiences, similar to other CBT approaches [25]. The central treatment process within ACT is psychological flexibility, which is the capacity to continue with or to change behavior guided by one’s values and goals despite the presence of interfering thoughts, emotions, and bodily sensations [26].

Psychological flexibility includes the subprocesses of acceptance, cognitive defusion, flexible attention to the present, self-as-observer, values-based action, and committed action [25]. Cognitive defusion methods aim to reduce the influence of maladaptive thoughts without necessarily changing the content of the thought [8]. Using acceptance methods, one engages in values-based behaviors despite unwanted feelings. One refrains from controlling feelings when these attempts block success [8]. Mindfulness processes include non-defensive, moment-to-moment, and nonjudgmental awareness [27]. It helps individuals to pay attention to current experiences without suppressing or elaborating those experiences [12]. This approach may be integral to decreasing automatic, maladaptive responses including hypervigilance to perceived threats and catastrophizing [28, 29].

Six randomized, controlled trials provide support for the use of ACT in treating patients with chronic pain [26, 30–34]. Consistent results include increased physical and social functioning as well as decreased pain-related medical visits [8]. A meta-analysis of studies of acceptance-based and mindfulness-based treatments for chronic pain found that these approaches seem at least equally effective as traditional CBT [35]. A study comparing CBT , mindfulness and acceptance treatment, and arthritis education found that the mindfulness and acceptance treatment yielded greater reductions in daily pain-related catastrophizing, morning disability, fatigue, and daily stress-related anxious affect than the other two conditions [12]. McCracken and Vowles [8] point out that ACT is a form of CBT that includes many similar methods.

Investigation of treatment process in an ACT trial for chronic pain reveals important findings related to pain, disability, and psychological distress. Increases in the acceptance of pain have been associated with improvements during treatment, which include reduced anxiety, depression, and disability [36]. Moreover, increases in values-based action correlate with improvements in anxiety, depression, and disability at 3-month follow-up [37]. Additionally, increases in acceptance of pain, mindfulness, and values-based action during the active phase of treatment significantly correlate with improvements in anxiety, depression, and disability, independent of changes in pain at 3-month follow-up [38]. Research supports that mindfulness-based methods are effective in chronic pain by virtue of symptom reduction and improved emotional functioning [27, 39]. Psychological flexibility mediates treatment effects on life satisfaction and disability [40].