CBT and ACT Therapy for Chronic Pain: How Does Psychotherapy Help?
Individuals with chronic pain share how Cognitive Behavioral Therapy and Acceptance and Commitment Therapy worked for them. By Rosemary Black Reviewed By Michael R. Clark, MD, MPH, MBA and Beth Dinoff, PhD
If you’re open to trying Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT), you may not only get relief from your chronic pain, but you may find that you feel generally more content with your life as well. CBT is a practical, hands-on, goal-oriented psychotherapy treatment that aims to change whatever patterns of behavior and thinking are at the root of a person’s difficulties. ACT, which based on behavioral therapy, encourages mindful, values-guided action. Rather than focusing on symptom reduction, ACT encourages the person to take actions that are based on her own values to hopefully enrich her life. (See more detail on each therapy at the end of this article.)
“ACT is about accepting your distressing symptoms or situation and not trying to resist or suppress them,” explains Michael Clark, MD, chairman of psychiatry and director of the Behavioral Health Service Line at the Inova Health System in Falls Church, Virginia. “Once you’ve accepted it, it is focusing on what would you like to be different, which is generally informed by what you value and what your life goals are. CBT is more about cognitively reframing your distress that is a manifestation of cognitive distortions like ‘I’m a horrible person’ or ‘The world is a negative place.’ The patient is asked to think about the evidence for these cognitions as well as evidence to the contrary, that is, finding positive evidence. Then the patient is asked to “behave” as if that positive evidence is really true, even if their negative feelings and distorted thoughts would suggest otherwise to them.”
Both ACT and CBT are typically covered by insurance and offered in conjunction with other treatments, explains Beth Dinoff, PhD, a clinical psychologist at the University of Iowa Hospitals and Clinics. “Pain management is always best provided as a multidisciplinary treatment,” she says. “Pain impacts all domains of peoples’ lives so the more life domains that are addressed usually leads to improved outcomes.” Dr. Dinoff, who practices ACT, notes that psychotherapists are not required to have special certification to provide CBT and ACT, although all clinical psychologists must have either a PhD or a PsyD degree, which allows them to provide psychotherapy to patients.You may be interested in these related articles:
“For people who are in pain and feeling demoralized, CBT and ACT can help with chronic stress, managing symptoms, decreasing anxiety, and improving problem-solving,” says Dr. Clark, who is also a member of the PPM advisory board.
Many other forms of psychotherapy focus on trying to ignore or suppress symptoms, explains Dr. Clark, “but with newer forms like ACT and CBT, instead of ignoring or suppressing their symptoms, people are taught to focus on their goals and their values. They learn to make changes in their life and to move forward to regain life satisfaction.”
Of note, in a PPM online reader poll, 73% said they have not yet sought out a psychotherapist as part of managing their chronic pain and related symptoms. Below are stories of two individuals who have tried and found success with ACT and CBT for combatting their chronic pain.
Using Acceptance and Commitment Therapy (ACT) to Experience Pain Differently
Kelly Teuscher of Davenport, Iowa, has suffered from chronic pain since she was a teenager, but countless treatments over the years yielded her little relief. With migraine, back pain, arthritis, Crohn’s disease, and diabetic gastritis, rarely does a day go by for Kelly when one of these conditions doesn’t act up (Read more about pain flares.)
Her doctors have tried just about everything: various medications, injections, and water therapy, but the pain remained. On one of her visits to a pain clinic in Iowa City, not far from where she lives, Kelly’s doctor suggested that she make an appointment with a psychiatrist. “At first, I thought to myself, they must think I’m crazy,” she recalls. “I just couldn’t see how seeing a psychiatrist would help.”
But after a consultation with the psychiatrist, she was referred for pain psychotherapy (also known as “talk therapy”) with Dr. Dinoff, who practices ACT. Kelly began to see Dr. Dinoff in March 2019, and after just four visits, she began to feel better.
“I’m amazed,” Kelly says. “It’s weird, but I feel calm. I am learning how to deal with my pain and how to put it in perspective. I’m no longer focusing on it.”
She says that practicing ACT has enabled her to view her life differently. “Every day, situations arrive that are challenging,” she admits. “But I’ve learned how to deal with various situations and take them for what they are, and this has made my anxiety go down. For the first time, I’m using my mind to deal with my emotions and feelings.”
Dr. Dinoff is a pain psychologist and clinical associate professor in the department of anesthesia in the Pain Management Clinic at the University of Iowa Hospitals and Clinics in Iowa City. She says that ACT teaches her clients how to live a full life despite their pain. “With ACT, we accept our negative internal sensations, pain being one of them,” she says. “But we do this in terms of living in service of our values. We hope that our patients will embrace learning to live a full life in the context of pain.”
How ACT Works: Metaphors, Values, and Flexibility
In addition to the use of metaphors, ACT stresses psychological flexibility as well as “cognitive diffusion,” in which the therapist strives to help the person get unstuck from thoughts, emotions, and memories that he or she may be attached to. “The person may be used to thinking they will always be in pain and never walk again,” Dr. Dinoff says as an example. “But that may not be true.”
How an individual relates to pain is important, Dr. Dinoff adds. “Often, people tell me that they just want their pain to go away completely so they try to push it away as hard as they can,” she explains. “But using an ACT metaphor, I invite the person to imagine they’re at the beach, swimming in the ocean, and holding a beach ball that they try to shove under the waves.”
Next, Dr. Dinoff has the person think about how much energy that would take, and then asks the person to consider the following: What if you just let the ball float on the surface of the water instead?
“The person begins to see how much effort it is taking for them to suppress the negative sensation of pain,” Dr. Dinoff explains. “Once they have these images of the metaphor, they can apply this to their own lives.”
Another metaphor she likes to use involves thinking about using a garden hose to water flowers. “If you put your thumb on the hose, it sprays all over and is out of control,” she says. “Instead, what would happen if you just let the water flow? With the ACT approach, learning to let go of behaviors, memories, thoughts, and emotions creates space to explore new experiences, including acceptance of chronic pain sensations.”
In ACT, the therapist is not trying to decrease a person’s chronic pain but rather to help the person focus on how they can change their behavior. Dr. Dinoff helps the patient to make the transition from feeling like a sick person with a lot of symptoms to an individual who can enjoy a satisfying life, a life of value.
Dr. Clark says he also has discussions with his ACT patients about how they can manage the chronic pain together. “It’s like trying to climb to the top of the cliff,” he explains. “You get on the wall and start making handholds and footholds and as you go, other handholds and footholds become more obvious and, pretty soon, you’re at the top of the cliff.”
With Acceptance and Commitment Therapy, the patient learns how to be present and non-reactive to unwanted negative physical or emotional circumstances, adds Dr. Sara Davin, PsyD, of the Cleveland Clinic’s Neurological Institute. “We talk about the values people have in their life and how their current situation is interfering with their ability to reach their life potential. There is a focus on acceptance and being willing to experience things.”
For Kelly, practicing ACT has not made her pain-free, she says, but it has paved the way for her to deal with her pain. “Once you get your mind right and learn to deal with situations and take them for what they are and not out of context, your anxiety goes down,” she says.
Since she started ACT with Dr. Dinoff, she is not only able to handle the physical pain better but also the emotional pain of having lost her sister two years ago. “I’ve been having some good discussions with my parents,” she shares. “I am taking much less pain medication than I was, and I’m getting more exercise.”
In fact, Kelly, her father, and her boyfriend of eight years bought a house together in April 2019. She and her boyfriend have a dog, she’s working, and she says that life is good. “I don’t feel so blue,” she says. “It’s all about using your mind to deal with your emotions and your feelings. In just four sessions, I have learned so much.”
Using Cognitive Behavioral Therapy (CBT) to Reframe Negative Thoughts and Avoidance
For many years, CBT has been the gold standard for pain psychology. Many patients and pain psychologists have found the approach to be very effective. For example, Deborah Cook of Birmingham, Alabama, who suffers both from rheumatoid arthritis and fibromyalgia, has seen so many doctors for her pain that she’s lost count.The mother of two children (ages 12 and 13), she’s tried everything from muscle relaxants to a transcutaneous electrical nerve stimulation (TENS) unit, but nothing has worked. She had just started on prescription opioid pills when she was referred to Leanne Cianfrini, PhD, a Hoover-Alabama-based pain psychologist who utilizes Cognitive Behavioral Therapy. And while Deborah says that the past several months have been difficult, she says that practicing CBT over the past 5 years has kept things from getting worse. “I might have ended up being hospitalized otherwise,” she says. “It has saved me.”
Typically, CBT and ACT are offered either as individual or group psychotherapy and both involve attending sessions of 45 minutes to 60 minutes each either every week or every other week. Dr. Dinoff notes that “both are as or more effective as group psychotherapies.” The approach allows the patient and the therapist to be “co-investigators,” explains Dr. Davin, of the Cleveland Clinic. “The way someone interprets their physical pain can impact their emotional state and how they respond to the pain, so it can be a vicious cycle,” she says. “Patients respond to pain in a fearful or catastrophic manner and feel hopeless and powerless, which are negative emotions.”
Deborah’s doctor, Dr. Cianfrini, adds that the collaborative style of CBT guides the patient to discover ways to reframe unhelpful or negative thoughts that can maintain pain. “It’s a perspective shift,” she explains. “It involves counter-arguments to thoughts that provoke negative emotions. For example, patients can get locked into a thought habit like, ‘I should be able to do everything I used to do’ and then feel discouraged when their pain cues them to rest a bit or pace themselves.” In this case, the therapist would work with the patient to generate an alternative thought process, such as, “My body is different now. I accept that I will pace myself today and be proud of what I accomplish.”
Or, adds Dr. Cianfrini, a patient living with chronic pain might anticipate pain with a certain activity. She might think, “I can’t sit through church (or a movie, or the ballgame).” A CBT therapist would gently guide the patient toward phrases such as, “Well, I could, if…” and generate behavioral techniques to accomplish their functional goals, she explains.
CBT can help people to change their way of thinking and how they regulate their emotions. Those who practice CBT can be taught to retrain their brain in a way that helps them experience less pain over time, she says. In addition to being collaborative, Dr. Davin emphasizes that “CBT is present focused, so rather than spending a lot of time digging into their past, we help the person understand where the negative thinking comes from and show them how to respond to pain in a less threatening way so they can have a better quality of life.”
Deborah shares that her life is much better than it was before she began CBT. “Even on my hardest days, I feel so much relief and I can function with the daily pain,” she says. “I have the tools to help me through the really bad days and my worth is not determined by what I am physically able to do. Some days, my best is getting my kids to and from school. Some days, I can get chores done and some days I can’t. I own my pain, but it does not define who I am.”
For help finding a psychotherapist, consider searching the American Psychological Association’s provider directory. You can search by location and then filter the treatment methods to those that offer cognitive/behavioral therapy. https://locator.apa.org/
Read also about how CBT can help with insomnia, a condition many individuals living with chronic pain experience.
Learn More about CBT and ACT
Cognitive Behavioral Therapy (CBT)
CBT is a present-focused, short-term, psychotherapy approach that encourages patients to engage in an active coping process to change their maladaptive thoughts and behaviors that oftentimes maintain and even exacerbate the experience of chronic pain. The cognitive-behavioral model is grounded in the idea of pain as a complex experience that is influenced by a patient’s thoughts and their effects, as well as one’s overall behavior. The goals of CBT in pain management include reducing the impact pain has on one’s daily life, learning skills for better coping with pain, improving physical and emotional functioning and well-being, and reducing reliance on pain medication.
CBT was developed as “Cognitive Therapy” in the 1960s by Aaron T. Beck, based off of a previous therapy called Rational Emotive Behavior Therapy (REBT) developed by Albert Ellis in the 1950s. CBT is typically administered by psychotherapists such as psychiatrists, psychologists, licensed professional counselors, licensed social workers, licensed marriage and family therapists, psychiatric nurses, or other licensed professionals (such as pain specialists) with mental health training.
Acceptance & Commitment Therapy (ACT)
ACT, developed in 1982 by Steven C. Hayes, is a distinct form of mindfulness-based intervention in that it is a behavioral analysis that uses acceptance and mindfulness strategies mixed with commitment and behavior-change strategies. ACT encourages patients to shift their focus from reducing or eliminating pain to fully engaging in their lives, changing how they relate with their internal experiences and ultimately living a better life. Therapists aim for patients to become actively involved in what they care about and what matters most in their life, despite having and experiencing pain. ACT applies six core processes (willingness to accept, contact with the present moment, observing the self, cognitive defusion, values, and committed action) through different exercises; these interventions provide patients to become more open, present, and take action in their lives.
While there is no official ACT certification for physicians, the Association for Contextual Behavior Science (ACBS) has a registry of members who identify as ACT therapists. According to the ACBS, those seeking ACT therapy may also look to contact the psychology, social work, or psychiatry department at a nearby college or university for faculty members who are experts in behavior therapy or CBT.
-Sidebar reported by Steven AlianoUpdated on: 12/16/19