Introduction

Psychosocial interventions have demonstrated efficacy in the management of chronic pain across a variety of pain types, settings and modes of delivery. The current “gold standard” psychosocial approach is Cognitive‐Behavioral Therapy (CBT) which has been shown to significantly reduce pain intensity, pain interference, disability and distress, as well as improve self‐efficacy and quality of life [1–3]. Moreover, research is now showing that CBT engenders measurable neurological functional and structural changes that are associated with pain outcome improvement [4, 5].

Arguably important to the delivery of any pain treatment (psychosocial or otherwise), is the provision of psychoeducation around the rationale for that treatment in order to gain patient buy‐in [6, 7]. Hence, an understanding of how pain is processed in the brain and how this is influenced by a complex interconnection between regions involved in not just the somatosensory aspect, but also areas associated with cognitions, emotions, motivations and behaviors is an important component of therapy.

We will therefore start this chapter by describing the therapeutic rationale for CBT with a focus on a simplified version of the “Gate Control Theory”. We will then provide an overview of those psychosocial factors that influence the processing of pain in the brain. Mapping on to this we will describe the techniques that CBT uses to target risk factors for poor pain coping and to enhance self‐efficacy and adaptive behaviors. We will provide an overview of the body of research supporting the efficacy of CBT, as well as touch upon some needed future directions.

How pain is processed in the brain: An overview and therapeutic rationale

With the advent of modern brain imaging techniques, it is now widely understood that pain is primarily the end result of supraspinal cortical processes which are influenced by a complex range of biopsychosocial factors [8]. This understanding was first described by Melzack and Wall in their revolutionary Gate Control Theory [9, 10], a theory that sparked the subsequent plethora of research testing the proposed brain mechanisms in pain and that is now known as the Neuromatrix model [11].

What has consistently emerged from the body of research testing and advancing this theory – using electroencephalography (EEG), magnetic resonance imaging (MRI) and functional MRI (fMRI) – is that a set of neural networks are reliably activated in response to pain and that these networks select, filter and modulate pain signals. Specifically, the majority of nociceptive pathways terminate in the thalamus, with thalamic nuclei responsible for then relaying sensory information to a highly distributed network including regions associated with pain processing (e.g. the primary and secondary somatosensory cortices, insula) and cognitive‐emotional demands (e.g. prefrontal cortex, anterior cingulate cortex, amygdala). Importantly, this functional network is not just the passive recipient of pain signals from the periphery, rather this network is actively involved in regulating and modulating the sensory perception of pain [12–16]. That is, this network can either “turn up the volume on pain” (i.e., leading to increased perceived pain intensity) or it can “turn down the volume on pain” (i.e., leading to decreased pain intensity), depending on a range of biopsychosocial factors.

Providing a simplified psychoeducational overview of this model, without jargon, and engaging patients in a collaborative discussion is an excellent way to provide a rationale for targeting psychosocial factors in treatment, which have the capacity to directly influence the processing of pain in the brain. The following points are important to emphasize: (1) Pain is not a sensation in and of itself, the brain – and many filters in the brain – determine the perception of pain; (2) Pain signals coming from the spinal cord are filtered through brain sites involving memory, emotion and thought processes; and (3) The brain activity in the filtering sites can enhance or diminish incoming pain signals (See [17] for additional details).

What “turns up the volume on pain” versus “what turns down the volume on pain”?

A vast body of research has consistently shown that chronic pain is influenced by a range of biopsychosocial factors including behaviors (at the individual and broader social level), emotions and cognitions. Research has reliably identified factors within each of these domains that are adaptive versus maladaptive and have the capacity to influence function, even in the presence of on‐going pain. In this section, we provide an overview of the most robust predictors of pain outcomes within each of these domains. Although the field has been predominantly focused on examining “unhelpful” and/or maladaptive aspects of pain, here we also note those factors associated with adaptive function that are important to emphasize and harness in treatment. Then, in the subsequent section, we describe how these factors are targeted by CBT techniques to improve pain management.

Behavioral and wider social factors. Fordyce [18] was one of the first to describe how behavioral factors contribute to the experience of chronic pain. Fordyce proposed that observable pain behaviors, such as limping, grimacing, resting and medication consumption (e.g. opioids) contribute to worse pain outcomes over time. For example, these behaviors may reinforce being a “pain patient” and they interfere with engagement in well behaviors, such as appropriately paced activity (as opposed to resting which contributes to muscular deconditioning). Although discussion of the current so‐called opioid epidemic is beyond the scope of this chapter, it is worth noting that the long‐term use of opioids for chronic pain is associated with significant side‐effects including analgesic tolerance, physical dependence, opioid‐induced hyperalgesia and risk of misuse, addiction and diversion and other negative impacts on function (e.g. sedation), with only modest effects on pain intensity [19–29]. Hence, while in the short term such medications might “turn down the volume on pain” it is also important to discuss with patients the ways in which, when taken long‐term, these medications can increase pain and disability and “turn up the volume on pain”.

Another major behavioral factor to address is avoidance, which has repeatedly been associated with heightened pain, more disability and lower return to work rates [30, 31]. The functional opposite of avoidance is engagement in paced activity as well as engagement in meaningful activities (or those that provide a sense of mastery). Recent literature reviews have demonstrated that appropriately paced engagement in valued activities despite the pain is associated with multiple positive pain‐related outcomes, including less pain intensity, depression, pain‐related anxiety, lower levels of physical and psychosocial disability and improved globally rated daily activity and overall emotional wellbeing [32–34].

Fordyce [18] was also a pioneer in emphasizing that pain does not occur in isolation, but rather it occurs within a social context. Demographically, women, racial and ethnic minorities, the elderly and those with low socioeconomic status have higher pain prevalence, more pain‐associated disability and greater levels of treatment disparities than their demographic counterparts [19]. Further, pain and disability affect work, family, leisure, healthcare and other environments. Vocational concerns (job stress, job dissatisfaction, vocational uncertainty and downward socioeconomic drift) and family concerns all feed into the complexities of pain and related disability. These in turn influence the behaviors, emotions and thoughts of the individual, as well as their pain. What has also been shown in the literature though is that social support – in the form of social, informational, behavioral and/or tangible sources – is associated with better pain‐related outcomes [35]. This adaptive role of social support can be built upon and harnessed in treatment via consideration of mode of delivery and whether group delivery, couples or family therapy modalities might be appropriate [35]. Within group‐delivered treatments, we have found that a common theme qualitatively reported by many participants is that the support provided by the group and the sense of “not being alone” was highly valued by individuals living with chronic pain [36].

Emotional factors. In the context of persistent pain, emotional concomitants naturally arise and for a proportion of people, emotional symptoms reach clinical levels. Rates of co‐morbid depression are estimated to affect up to 50% of people [37–39], and rates of anxiety disorders (most commonly Post‐Traumatic Stress Disorder, Panic Disorder and Generalized Anxiety Disorder) affect up to an estimated 57% of people [40–42].However, these are likely underestimates as psychological co‐morbidities typically go undiagnosed and undertreated.⁴³ Co‐morbid depression and anxiety are important to assess and treat in the context of chronic pain though, as these conditions are associated with an array of worse pain outcomes [44, 45], including interference with treatment and premature drop‐out [43, 46, 47]. Furthermore, symptoms of anxiety and fear might be a particularly common response when the source of pain is undiagnosed. In this context, the Fear Avoidance Model of pain [48, 49] proposes that widespread fear of increased pain or of injury or re‐injury, is subsequently related to behavioral avoidance and significantly contributes to disability among individuals with chronic pain. In support for this model, research has shown that fear‐related factors more accurately predict functional limitations than even pain severity, pain duration or other biomedical factors [30, 50].

The potential buffering role of resilience and positive affect/emotion has been a topic of increasing investigation over the past decade. Research supports the role that positive emotions play in fostering recovery from pain flare‐ups [51]. Further, subjective happiness and humor have been linked to improved pain thresholds, reduced pain intensity and the release of endorphins, as well as better general health in chronic pain [52–56]. Thus, appropriate use of positive themes and humor in therapy – which has at various times been recognized as a feature of cognitive therapy – might not only contribute to facilitating therapeutic bonds, but also might improve pain outcomes [56, 57].

Cognitive factors. Given the important contribution of negative thoughts to distress and unhelpful behavior, psychosocial interventions often focus on cognitive content or habits of processing. Negative thoughts about pain have been organized into descriptive categories such as threat and harm appraisals (e.g. “pain is life‐threatening”), automatic thoughts (e.g. “I can’t cope with this pain”) acquired beliefs about pain (e.g. “pain should be treated with rest and medication”) and deep beliefs about oneself (e.g. “I am a failure”).⁷ Generally, though, research often focuses on negative thoughts about pain in relation to pain catastrophizing [58]. Across various theoretical models (including the Fear Avoidance Model noted above [48] as well as the Communal Coping Model [58]) pain catastrophizing is theorized as the antecedent to engendering fear and maladaptive pain behaviors, including avoidance. An extensive body of research has consistently shown pain catastrophizing predicts a range of poor outcomes, including pain intensity, disability, poorer social functioning, longer recovery times following surgery, greater healthcare utilization and worse mood (e.g. depression and anxiety), even when important covariates such as disease severity, pain intensity, anxiety and neuroticism are controlled [59–66].

The other cognitive variable that repeatedly emerges as critical to bolster in pain management programs is self‐efficacy [67]. This is the belief that one can manage pain and initiate strategies to achieve personal goals despite continuing pain [69]. Self‐efficacy represents an example of a positive appraisal that has been shown to be important in pain. Other cognitive process variables are also emerging as protective in the context of chronic pain. Two such cognitive processes are mindfulness and pain acceptance, both of which have been shown to predict an array of positive outcomes including lower pain intensity, negative affect, pain catastrophizing, fear of pain, pain hypervigilance and disability [69, 70]. Although CBT does not theoretically target the cognitive process variables of mindfulness or pain acceptance, research suggests CBT does result in improvements in mindfulness and acceptance and that these processes might be important to the positive outcome gains achieved in CBT [71].

Cognitive‐Behavioral Therapy for chronic pain management

Psychological pain treatments have developed considerably over the past 50 years, as have treatment targets. The operant approach was the first systematically applied psychological treatment for pain and focused on overt behavior [18]; the respondent and stress management approaches which followed tended to emphasize muscle tension [72]. Family, couples and system therapies addressed interpersonal processes and conflict [35, 73]; and, more recently, mindfulness‐based stress reduction [74, 75] and mindfulness‐based cognitive therapy [6], as well as acceptance and commitment therapy [76, 77] have been successfully applied for improving a range of pain‐related outcomes. To date however, of the psychological approaches that have been shown to be helpful for chronic pain, CBT has accumulated the most high quality evidence to support its efficacy.

The CBT approach for chronic pain management took hold in the 1980’s following the early behavioral work [78–80]. Since this time, CBT has accumulated empirical support across various types of pain, settings, populations and modes of delivery with respect to its efficacy and cost‐effectiveness, with these benefits maintained at short‐ and long‐term follow‐up [3,81–88]. Most of the research to date has established the efficacy of CBT within adult populations with chronic back pain, headache, orofacial pain or arthritis related pain, with a smaller number of trials completed within other pain conditions [1, 88]. Further, more recent research by Seminowicz and colleagues⁴ has demonstrated the positive outcomes associated with CBT extend beyond self‐report indicators, with increased gray matter volume in several areas of the brain related to pain processing found following an 11‐week CBT treatment. Based on the wealth of high quality, well‐controlled trials supporting the use of CBT for chronic pain, it is currently considered the gold standard psychological treatment approach [1–3, 88

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