Does it work? CBT cannot cure your physical symptoms, it can only help you cope better with them. It may reduce the level of disability you experience because of the pain without reducing the pain or it may just improve your mood. Studies suggest its impact is only likely to be small to moderate, but reliably better than no treatment at all.
Who does it work for? Because it's about changing your thinking and behaviour, not treating your pain directly, it can work for people with any type of pain. However, its results will vary from person to person, and given that some reviews of trials conclude it works best on mood, it may work best for people who experience low moods because of their pain.
Who doesn't it work for? Not everyone who tries CBT benefits. I wasn't able to find evidence which predicted in advance which people were more or less likely to benefit from it, although if you already have a positive mood most of the time and/or have already optimised your thinking, behaviour and coping strategies, you may not get additional benefit. The question here is whether you have genuinely already optimised your strategies, or whether CBT ideas and exercises could give you additional help.
Where can I get it? Clinics of pain education (COPEs) tend to offer it as part of their services. In theory you could be referred for CBT directly by your GP, but given the current financial constraints on the NHS, some or all GPs may be unwilling to refer patients directly for NHS treatment, although they may be able to recommend a CBT therapist for you to see privately. Alternatively, a register of all the accredited CBT therapists in the UK is available here. It is worth checking if the therapist you are thinking about seeing knows about using CBT to treat chronic pain, as treatment of pain is not the commonest use of CBT and it's possible that pain treatment differs either slightly or a lot from treatment of other problems. According to Wikipedia, you can also get CBT in group sessions or in computerised form (e.g. an app) or by reading self-help materials.
How much does it cost? If you can get it on the NHS it is free. If you have to pay to see a therapist privately, according to the NHS website the cost is usually between £40 and £100 per session, sessions are generally 30-60 minutes. WebMD says you will probably need between 8 and 24 sessions plus possibly booster sessions for chronic pain.
Is there a cheap/free version? You can buy a book on CBT and apply the techniques from there. I haven't tried any books, but Overcoming Chronic Pain:A Self-Help Guide Using Cognitive Behavioural Techniques gets 4 stars on Amazon and only costs £7.49 on Kindle, from £2.99 used or from £7.11 new. If this book includes exercises, it may help to get a friend or family member involved to encourage you to complete all the exercises, for instance checking up on whether you have done the exercises, as it is all to easy to simply stop reading a book or skip the exercises.
Alternatively you can get free CBT apps for your phone. Look up CBT in the Google Play Store or iTunes. Most of these are aimed at depression or anxiety and none at pain, but some seem to be more general CBT information, and in fact some of these techniques are likely to also apply to chronic pain anyhow. Also, if your pain is causing you depression or anxiety, then these apps are particularly appropriate.
I've briefly tried Cognitive Styles CBT Test, which tests your tendency to think in a way that CBT thinks will be to your benefit or detriment. Despite passing most of the test with flying colours and getting roundly praised, I found its assumptions about what some of my answers meant irritating. On the other hand, I have quite a long history of finding this sort of thing irritating, so I suspect I'm not the ideal target, and if you're less irritable than me it may give you some useful areas to think about. I also tried CBT Thought Record Diary. I liked this a lot better, and filled in my first diary entry about my irritation with the previous app. I found this helpful (it actually dissipated my irritation), but I have existing knowledge of CBT thinking styles and errors due to my reading and listening interests. I think you need this knowledge to use the app well. You could gain these by reading a book or even just by reading information such as this about them on the Internet. Please note though, that this only enabled me to decrease the length of time I spent irritated at the previous app, it gave me no help whatsoever for my pain (although perhaps if I had used it on a pain-specific negative emotion it would have worked for that). You may or may not be able to adapt a non-specific CBT diary to your pain issues - although irritation at medical professionals and treatments offered that completely fail to understand my situation is actually part of my pain problem and something I think most people with chronic pain are likely to face, so you can certainly try it for that.
According to Wikipedia, NICE recommends computerised CBT for mild to moderate depression, but doesn't recommend a specific product or anything specific to pain. You might be able to access this via your GP if your GP deems it suitable for chronic pain or you also have mild to moderate depression. I'm not clear if the NHS has any computerised or Internet-based CBT available that is suited to chronic pain and I was only able to find apps for smartphones available to the public and did not come across any other software you could buy (search size: lazy - I googled it and never got past the first page).
Does the individual practitioner matter? Yes. Studies of of psychotherapeutic treatment show that the top determinant of outcome is whether or not the patient likes the therapist, so find a therapist you like - even on the NHS you have the right to request a different therapist. Also, I find that some people's explanatory styles are likely to be a better match for the way you learn and understand than others. I find it really hard to get help from someone who I dislike or someone who explains things in a way that's meaningless to me. The same applies to books that are written in a manner that doesn't work for how I think and/or irritate me.
Is there any evidence for it? Reviews suggest CBT holds its own compared with usual care or no treatment at all for pain-related problems, with small to medium effects on pain intensity, catastrophising and mood, and small effects on pain-related disability and activity interference (not doing things because of pain). This conclusion and the reviews I looked at come from this paper by researchers at the University of Washington. The paper reviewed studies and reviews on the impact of CBT on chronic pain, but was not a systematic review so may be subject to bias and omission, but it does have a focus on statistical significance, which is something I approve of (statistically significant findings = reliable findings). I didn't look for any further trials. To be frank, when I present evidence, I am usually only presenting what I can find by trawling the Internet for 60 minutes or so, so this is no worse than that (proper systematic reviews take a lot of time and are usually done by professional researchers).
Here's my summary of what they found with links to the original reviews and meta-analyses:
CBT for chronic pain in general:
A 2012 Cochrane review concluded that, compared with treatment-as-usual or wait-list control conditions (wait-list controls = people who do not get treatment until after the trial), CBT had statistically significant (i.e. we can trust these findings) but small effects on pain and disability, and moderate effects on mood and catastrophising, after treatment. By 6 to 12-month follow-up, however, the only significant effect was for mood. Compared with people getting other treatment, CBT was not superior for pain or mood outcomes.
CBT for chronic back pain:
A 2007 meta-analysis of 22 randomised controlled trials of psychological treatments for chronic back pain indicated that psychological interventions had positive effects on pain, pain-related interference with activities, health-related quality of life and depression compared to various other treatments or non-treatment. CBT was found to be better than not receiving treatment for improving the intensity of pain after treatment but not for health-related quality of life or depression. A 2010 Cochrane review of behavioural treatments (including CBT) for chronic low back pain, which included 30 randomised controlled trials, concluded that behavioural treatments were more effective than usual care for pain after treatment but no different in intermediate to long-term effects on pain or functional status (i.e. what you can and can't do). There was little or no difference between behavioural treatment and group exercise in improving pain and depressive symptoms over the intermediate to long term. However, for most of the comparisons there was only low or very low-quality evidence, and there was no high-quality evidence for any comparison (i.e. the evidence wasn't very reliable).
CBT for headaches:
A 2007 review of behavioural treatments for headaches described CBT-based interventions (relaxation, biofeedback and cognitive therapy) as reducing headache activity 30%–60% on average across studies. These effects surpassed those of other treatments/non-treatment and were typically sustained over time, including years after treatment.
According to this review, biofeedback interventions are commonly used in treating chronic headaches, either as a stand-alone treatment or in conjunction with other CBT techniques.
CBT for chronic oro-facial pain:
A 2011 Cochrane review of psychosocial interventions for chronic oro-facial pain concluded that CBT, either alone or with biofeedback, resulted in long-term (more than three months) improvements in pain intensity, depression, and pain-related activity interference; however, the authors called for more rigorous studies to substantiate these conclusions, saying that there was weak evidence to support the use of psychosocial interventions for chronic oro-facial pain and although significant effects were observed for outcome measures where pooling was possible, the studies were few in number and had high risk of bias.
CBT for rheumatoid arthritis:
A 2002 systematic review found that psychological interventions may be important adjunctive therapies in the medical management of rheumatoid arthritis, but that psychological interventions may be more effective for patients who have had the illness for shorter duration. A 2010 systematic review, noted that comparative analyses revealed that interventions utilising more self-regulation techniques reduced depressive symptoms and anxiety significantly more than interventions utilising fewer such techniques and also that depressive symptoms were reduced significantly more among recently diagnosed rheumatoid arthritis patients than among those with long-standing rheumatoid arthritis.
CBT for fibromyalgia pain:
A 2010 analysis found cognitive-behavioural treatment to be significantly better than other psychological treatments in short-term pain reduction. Higher treatment dose was associated with better outcome. Publication-bias analyses demonstrated that the effect sizes were robust. The results suggested that the effects of psychological treatments for fibromyalgia were relatively small but robust and comparable to those reported for other pain and drug treatments used for this disorder. Cognitive-behavioural therapy was associated with the greatest effect sizes.
Are there any negatives? CBT takes time and effort (and if you have private sessions also a lot of money). Its effect is only likely to be small to moderate and it may not work for you at all. You may access it in a way that irritates you or isn't meaningful to you and you may have difficulty applying information from a book or keeping going with the exercises. I also dislike the impression I sometimes get from medical professionals that because CBT can be used for pain and may reduce disability levels, this implies that part of my level of disability is due to my attitude and that CBT can reverse disability or prevent further disability (this is far from proven) and that they want me to change my attitude through CBT instead of dealing directly with the disability or problem I currently have. This may actually be an example of mind-reading on my part, and CBT suggests I should test this assumption by checking with the medical professionals if this is really what they mean or if they are just out of ideas and CBT is the last weapon they have left in their arsenal and we're now down to things that only have a small impact on my mood instead of genuinely improving my pain or disability levels. Overall though, given that CBT ideas even help me investigate why I dislike people suggesting CBT to me so much, I'd say it's worth at least knowing what the thinking errors or cognitive distortions that CBT tries to deal with are, and if you think it is something that could be helpful to you, then pursuing it further, whether that's simply by reading a book or by other methods.
Anything else worth knowing? It's drug-free and may improve your mood and therefore your life in general. Also, if you like this method of trying to understand how your thinking and behaviour affect your well-being (or if you like the idea in theory, but dislike the way CBT is presented), you may also like to try reading the book Buddha's Brain.
Was it worth the money/effort? For me it is unlikely to be. According to WebMD my belief that it is unlikely to help me and will at best provide a small effect – probably on my already generally positive mood – means it's even less likely to work for me than for someone who believes it will work. I generally agree with the idea of avoiding the cognitive distortions CBT talks about, but actually I wasn't particularly prone to those in the first place, and suffer practically no anxiety and mainly already have a positive mood (admittedly with spots of temporary irritability), so the effects it's most likely to have (effects on mood) aren't in an area where I need much help. I also have a tendency to test out what I can and can't do and what the pain cost of doing those things is for me. It is possible it could have additional benefit for me and I have decided to give it a fair chance and complete the programme if the next clinic of pain education I'm booked in for offers it. I'm even thinking about buying and reading that book I found when researching this post. On the other hand, for me it definitely wouldn't be worth paying the over £1000 a private course of sessions could easily run to.
Have you tried CBT? Was it successful for you? Did you have to believe in it first to get the benefits? What benefits did you get? Were there any unexpected bonus benefits? Can you recommend a particular app or book? Or did it not suit you, and can you identify why that was?
