CBT Pain Research Review

CBT TREATMENT OF PAIN

 RESEARCH REVIEW

Cognitive Behavior Therapy (CBT) is the most well-known and well-researched psychological treatment for chronic pain. This approach is based on a conceptualization that chronic pain is maintained or at least exacerbated by maladaptive thoughts, feelings and behaviors and that changing these can alleviate pain and the psychological distress that it causes. The main elements of CBT treatment of pain are challenging negative beliefs, relaxation training, activity scheduling (pacing) and goal-setting (Turner & Keefe, 1999) CBT is generally regarded as having a strong research base. A recent meta-analysis concluded that there is “good evidence” for the effectiveness of CBT in the treatment of chronic pain (Morley, Eccleston & Williams, 1999).

However, a wider review suggests that conclusions regarding CBT’s efficacy with pain vary. A more recent review of meta-analyses concluded that CBT produced “moderate” effect sizes for chronic pain (Butler, Chapman, & Forman et al, 2004). The Cochrane Library review concluded that CBT can help reduce mood problems and disability associated with pain but that it has “weak effects” in improving pain (Eccleston, Williams & Morley, 2009).

The difficulty with evaluating CBT is that much of the research regarding CBT treatment of pain is undermined by methodological problems such as differences between treatment groups, attrition and a paucity of evidence regarding the persistence of CBT effects (|Turk & Rudy, 1990, Morley, Eccleston & Williams, ibid, Butler, Chapman, & Forman et al, ibid). It has also been noted that patients who attend pain clinics may not be representative of persistent pain sufferers in the community (Crook, Tunks & Rideout et al, 1986, Turk & Rudy, 1990, Turk 2005).

Another problem with CBT is its adoption of the concept of secondary gain. Secondary gain is a psychoanalytic term which refers to perceived advantages or ‘gains’ patients derive from their symptoms. For example, Nicholas (1996) writes; “a person seeking help for chronic pain could be said to be inactive with secondary physical deconditioning, to hold unhelpful beliefs, to be overly passive or reliant on others for resolution of his/her problems..” In a recent study where women chronic pain sufferers were found to have greater levels of disability than men, it was speculated that perhaps they were using the pain as an excuse to stay at home, something the author described as “a powerful secondary gain.” (Gatchel 1995).

This concept appears to have been over-used with harmful effects for chronic pain sufferers. For example, Pilowsky (1996) warned of the danger of an approach which emphasizes patients ‘taking responsibility’ for their pain becoming a basis for patients being blamed for poor treatment outcomes. Eccleston et al (1997) noted that many pain patients were confused and angry at treatment which seemed to focus on their own behavior and of being blamed for their own suffering and misery. May et al (1999) has observed that the disparity between expressed symptoms, pathological signs and perceived disability in CLBP has led to the moral character of the suffer forming a constant subtext to medical discourse about the condition.

These problems suggest that that at the very least, there is room for considerable caution about what we think we know about effective treatments for chronic pain. It is remarkable that there is not more debate about the limitations of existing approaches. There would also appear to be room for consideration and exploration of other approaches including EMDR.

References

ButlerAndrew C. Chapman , Jason E. Forman, Evan M and . Beck, Aaron T. (2006)

The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review 26, 17-31.

Crook J. Tunks, E., Rideout, E, and Brown, G. (1986) Epidemiological comparison of persistent pain sufferers in a speciality pain clinic and in the community. Arch. Phys. Med. Rehab. 67, 451-455.

EcclestonC. Williams AC de C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 2009, issue 2. Art.No.:CD007407:DOI:10:1002/14651858.CD007407.pub2..

Turk Dennis C., & Rudy, Thomas E. (1990) Neglected Factors in chronic pain treatment outcome studies – referral patterns, failure to enter treatment, and attrition. Pain, 43. 7-25

Turk, Dennis C. (2005) When is a Person with Chronic Pain a Patient? APS Bulletin. 15(2). Downloaded on 9/6/12 from http://www.ampainsoc.org/library/bulletin/spr05/pres1.htm

Turner JA, Keefe FJ. (1999) Cognitive-behavioural for chronic pain. Pain 1999; An updated review: 523 533

Williams, B.A. (2010). Perils of evidence-based medicine. Perspectives on Biology and Medicine, 53, 1, 106–120