A recent review of chronic pain therapies in Inpsych, the magazine of the Australian Psychologist, focused on only one method, Cognitive Behavioral Therapy (CBT). CBT is the most researched pain management approach and forms the basis for the vast majority of self-help books. It’s based on the premise that negative thinking and behaviour exacerbate chronic pain and that reversing these can alleviate the suffering associated with this problem. At face value this is a fairly reasonable set of suppositions. CBT has been found to have small short-term effects on mood, disability and negative thinking. However, another independent review of CBT found the approach wanting. Here are 8 things that your CBT-oriented pain-management psychologist will never tell you:
- The theoretical basis of CBT is deficient. Eg; “A simple model of independent deficits in cognition, emotion or physical function to be remedied by independent components of therapy is inadequate.
- There is no evidence for some its core assumptions (eg; increasing physical strength through activity). Eg, “Assumptions of deconditioning and poor physical status in chronic pain have proved to be unsubstantiated.”
- The strategies that CBT recommends (eg; changing your thinking, increasing physical strength through activity) simply don’t work for many people. Eg ([overall] “CBT results in small short-term effects on pain and disability, more enduring for mood.”
- When CBT is helpful they don’t know what elements of the treatment are effective – there is some research that points to the therapeutic relationship rather than anything the therapist does being the most important thing.
- Treatment gains are no better for CBT than for surgery.
- After all this time and research the reviewers concluded that
the evidence base for CBT treatment of chronic pain is “weak” – the lowest possible rating above ineffective. This is remarkable given that articles regularly appear in the popular press espousing this method as highly effective for alleviating the suffering associated with chronic pain.
- The reality is that people are different and different things work for different people. Okay, the authors did admit that CBT doesn’t work for everybody, but they have no idea why it doesn’t work for the 30% of people they would admit to it not working for. This is an embarrassing travesty; thousands of psychological researchers, and clinicians, who do not know how to assess personality factors when choosing appropriate treatments! Oh, they only have one treatment so that kinda limits what can be done.
- There are other less researched but promising treatments for chronic pain, such as EMDR. EMDR is more consistent theoretically and practically with brain functioning; it acknowledges the role of trauma in maintaining pain, and it can stimulate pain relief, which is not even a goal of traditional CBT. I have also done research on who EMDR works for and who it doesn’t and will make this the subject of another blog.
Most chronic pain psychologists can’t or won’t tell you these things because they are either hooked on the mythology about CBT, restricted in what treatments they can offer because of the emphasis many treatment providers place on ‘scientifically validated treatments’ or just plain scared of trying something different. Don’t give up hope but do know that there is more than one treatment for chronic pain, it is not your fault if the treatment seems to be failing, and that this is an evolving field where new treatments are emerging all the time. You are allowed to ask your treatment provider about the research basis for the treatment being recommended. The Cochrane Library, where the review on which this blog is based was published, is an excellent unbiased resource. This is the information age – you need to do your own research and be an active consumer of health services.
Alexander, Harriett (2015) Train your brain to feel less pain. The Sydney Morning Herald. May 10, 2015. http://www.smh.com.au/nsw/train-your-brain-to-feel-less-pain-20150509-ggxvqq.html
Eccleston C, Williams AC de C, Morley S: Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews, issue 2. Art.No.:CD007407:DOI:10:1002/14651858.CD007407.pub2. 2009
Grant Mark (2015) Neuropsychology of Chronic Pain and Eye Movement Desensitization and Reprocessing. The Neuropsychotherapist, 14 May 2015. p 15-23.