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1. Nonpharmacological
Pain Management
Cognitive Behavioral Therapy for Pain (CBT-CP)
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs Counselor Education
Host: Counselor Toolbox Podcast
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2. Objectives
 Types of pain
 Impact of pain on sleep, HPA-Axis and mood
 Treatment options for chronic pain
 CBT Interventions
Based in part on: Murphy, J.L., McKellar, J.D., Raffa,
S.D., Clark, M.E., Kerns, R.D., & Karlin, B.E.
Cognitive behavioral therapy for chronic pain among
veterans: Therapist manual. Washington, DC: U.S.
Department of Veterans Affairs. Pages 10-12, 15-88.
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3. Types and Locations of Pain
 More than 20% of US adults have chronic pain
(cdc.gov)
 Chronic pain
 Lasts more than 3 months
 May have a known or unknown cause
 Persists beyond expected healing time or despite
treatment
 Best conceptualized as a condition to be managed
rather than cured
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4. Types of Pain
 Nocioceptive Pain
 Pain that is caused by damage to body tissue and is
based on input by specialized nerves called nociceptors
 Most nociceptive pain is musculoskeletal, and is often
described as aching or deep
 Examples
Back and neck pain
Arthritis/Gout
Tendonitis
Bursitis
Pelvic floor disorders
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5. Types of Pain
 Neuropathic Pain
 Occurs when there is nerve damage that typically involves
either the peripheral or central nerves
 It is often described as burning, shooting, tingling, or
electric
 Examples
 Radicular pain—radiates along a nerve (sciatica)
 Phantom limb
 Fibromyalgia
 Peripheral neuropathy
 Spinal tap/epidural
 Carpal tunnel
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6. Types of Pain
 Headache Pain
 Tension (15 days/month for at least 6 months)
 Cluster (15-180 minutes every other day to 8x/day)
 Migraine (2-72 hours)
 TBI (may last 6 or more months)
 Cervicogenic (referred pain from the neck/cervical
spondylosis or fracture)
 Medication Overuse/Rebound Headaches
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7. Treatment Options
 TENS units (Neuropathic or Nocioceptive)
 Massage
 Physical Therapy
 Stretching
 Ergonomics
 Heat/cold
 Chiropractics
 Acupuncture/Acupressure
 Yoga/Tai-Chi
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8. Treatment Options
 Biofeedback: Noticing HPA-Axis activation and responding with
relaxation exercises
 Relaxation Training
 Mindfulness
 Cognitive Behavioral Therapy (CBT) addresses thoughts,
behaviors and emotions associated with pain
 Observable behaviors such as grimacing, sighing, or limping are often
socially reinforced and can lead to increased self-perceptions of pain
 Negative thoughts and emotions can lead to increased pain perception
 Acceptance and Commitment Therapy (ACT) aims to develop
greater psychological flexibility and learn to “live in the and.”
 Hypnotherapy
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9. CBT-CP Theoretical Components
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When pain is experienced (a situation), a person may feel discouraged and
frustrated (emotion) and think, “if I try to do anything today I’m just going to
hurt more” (thought), “so I will avoiding moving for the rest of the day”
(behavior).

10. Factors Maintaining Pain
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11. Psychological Factors Associated with Pain
 Pain Cognitions. Negative cognitions and beliefs about
pain, including catastrophizing can lead to maladaptive
coping, exacerbation of pain, increased suffering, and
greater disability
 Negative Affect. The relationship between pain and
negative affect is complex and bidirectional.
 Hurt versus Harm. When pain is interpreted as evidence
of further damage to tissue rather than an ongoing stable
problem that may improve, individuals with chronic pain
will report higher pain intensity regardless of whether
damage is occurring (Smith, Gracely, & Safer, 1998).
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12. Psychological Factors Associated with Pain
 Answer-Seeking. Failing to accept the offered cause
of pain or being unwilling to accept that a source of
pain cannot be determined can lead to increased
distress and pain intensity
 Pain Self-efficacy is the level of confidence that
some degree of control can be exerted over the pain.
 Help people reconceptualize pain and move from a view of
pain as purely sensory/biomedical to more multidimensional
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13. Social Factors Associated with Pain
 Solicitous significant other who is highly responsive to
an individual’s pain or to expressions of behavior
indicative of pain results in increased reports of pain.
 Increase social interactions that focus the individual’s
attention away from pain and onto different topics or
activities.
 Punishing responses involve either angry or ignoring
responses, each aimed at limiting expression of pain
 Potential consequences of punishing responses include
dramatic (loud) expressions of one’s pain experience in an
effort to be “heard” or, alternately, to stoicism and
resignation.
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14. Behavioral Factors Associated with Pain
 Guarding
 Resting/under-activity
 Overactivity (ignoring the pain)
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15. Impact of Pain
 Emotionally
 Cognitively
 Physically
 HPA-Axis
 Secondary problems
 ADLs
 Interpersonally
 Occupationally
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16. Chronic Pain Cycle
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17. The Chronic Pain Experience
 Those who struggle with chronic pain and associated functional
impairments may feel frustrated and disappointed that they have
not received the answers regarding the cause of their pain, or
effective treatments.
 They often feel as if they have not been “heard” and complain
that doctors have not taken the time to listen and understand.
 Some people also feel that they have been treated as if they are
“crazy,” and that the pain is all in their head.
 Others may feel that they have been unjustly labeled as “drug
seeking” when they are only looking for a way to feel better.
 Factors such as these may cause those with chronic pain to
present at the initial session with doubts that anything will help.
 Remember the pain is emotional and physical
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17

18. Chronic Pain Experience--Issues
 Many people expect to rely on passive treatment,
often that provide rapid relief
 Surgery
 Injection
 Chiropractics
 Massage
 Emphasize the benefits of self-managed, active
approaches. A chiropractor is not going to be
available at 2am.
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19. Chronic Pain Experience--Issues
 Develop a list of active approaches the person can
use:
 Stretching
 Relaxation
 Hot/cold
 Guided Imagery
 Alternate focus
 TENS
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20. Chronic Pain Experience--Issues
 Changing or Vague Complaints
 Some people are more comfortable focusing on somatic
rather than emotional complaints
 As treatment progresses, complaints may change
When back pain is lessened, the person may notice other
pain issues more. (Embrace the dialectic)
 They may also complain of fatigue or malaise.
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21. Chronic Pain Experience--Issues
 When the location of the pain shifts
 Get new pain evaluated by a medical provider
 Redirect to the primary pain and notice the improvements
 Remind the person of strategies to manage original pain and
apply them to new pain
 Identify cognitive, emotional or behavioral issues
contributing to that and effective solutions
 “What has changed that is causing to feel more tired/sick?”
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22. Chronic Pain Experience--Issues
 When complaints are vague it may be
countertherapeutic to focus on them
 You can also consider using a transdiagnostic approach
and identifying possible neurotransmitter/HPA-Axis
related issues
I feel achy
I am fatigued
Difficulty concentrating
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23. CBT-CP
 Assessment and Interview
 Pain Rating: Frequency, intensity and duration
 Pain Catastrophizing Scale (Sullivan, Bishop, & Pivik, 1995)
Assesses tendency to ruminate, magnify, & feel helpless about pain
 Assess interference of pain in various areas such as socialization,
work, daily activities, and relationships with others including
family/marital
 Assess the existence and severity of depression and anxiety
symptoms, which have a high co-occurrence with pain
 Assess perception of quality of life regarding: physical health,
mental health, relationships, and environment
 Gather treatment plans from medical providers
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24. CBT-CP
 Assessment and Interview cont…
 Identify times when the pain is better (increase)
 Identify strategies that help reduce pain (increase)
 Identify triggers/exacerbators of pain (mitigate/decrease)
 Goal Setting (Specific, Measurable, Achievable,
Relevant, Time Limited)
 Reduce the negative impact of pain on daily life (AEB)
 Improve physical and emotional functioning (AEB)
 Increase effective coping for pain (AEB)
 Reduce pain intensity (AEB)
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25. CBT-CP
 Physical Activation and Pacing
 Importance of movement and thoughtful approach to
activities (Spring clean on a “good day”)
 Use tracking logs for activity, duration, intensity, pain
before, immediately after, and before bed
 Increasing motivation for implementation of PT plan
 Decisional Balance
 Avoiding activity increases pain over time because of
decreased flexibility and stamina, increased weakness and
fatigue, spasms from tight muscles
 These things cause increased risk of injury and weight gain
(adding strain to the body) as well as feelings of sadness,
guilt, frustration, or boredom, which encourages withdrawal
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26. CBT-CP– Pacing cont…
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• Take breaks based on how much time you have worked not on how much
you have accomplished
• Take breaks before the pain begins to increase, not after it gets bad
• Practice makes perfect – your body must learn how to respond

27. CBT-CP
 Relaxation
 Techniques
 Deep breathing (triggers relaxation response)
 Progressive muscular relaxation
 Guided imagery
 Laughter
 Pair relaxation with daily activities
 Use a relaxation “app”
 Add relaxation minutes to prevent muscle tension buildup
 Obstacles
 I’m in too much pain to relax (Bidirectional pain scale)
 I have to keep moving (Danger of overdoing it)
 I relax all the time (Relaxing is different than resting/lounging)
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28. CBT-CP
 Pleasant Activities
 Educate about the benefits of pleasant activities:
Distraction, improved mood, socialization, enhanced
direction and efficacy
 Make a list of pleasant activities
 Encourage daily engagement to make life worth living
despite pain
 Encourage positive journaling
 Sleep
 Educate about the importance of sleep for mood and pain
 Discuss sleep hygiene and make a sleep plan
 Youtube.com/AllCEUseducation Effect of Sleep on Mood
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29. CBT-CP
 Cognitive Strategies
 Identifying, understanding, monitoring and addressing
automatic negative thoughts (ANTs) and how they
impact pain experience
About the problem
About the functional impact of their problem
About their ability to impact pain levels
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30. CBT-CP
 Cognitive Strategies
Catastrophizing.
 “It is a tumor” “This will end my career and I will be
unemployable.”
Emotional Reasoning
 “I am scared about what is causing the pain, so it must be bad”
Overgeneralization
 “I cannot play ball with my son anymore so I am a terrible
parent”
All or Nothing
 “If I have pain, my life is miserable”
 “I am always in pain”
 “I am never comfortable”
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31. CBT-CP
 Cognitive Strategies
 Minimization of the positive
 “Yeah, my back is feeling better, but I’m sure it won’t last”
 Mind Reading
 “My kids hate me because I can’t do the things with them that I
used to.”
 Jumping to Conclusions
 “If I have pain now, I will always have pain.”
 Mental Filter
 “Nobody understands.
 Control Fallacies
 “I have no control over my pain or the way it impacts my life”
 “If I just _____ then the pain will go away”
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32. CBT-CP Automatic Negative Pain Thoughts
 Have participants list their Automatic Negative
Thoughts (ANTs) as they relate to
 Their pain
 Their relationships (because of their pain)
 The probability of treatment success
 Their quality of life (because of their pain)
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33. CBT-CP—Cognitive Distortions Worksheet
Cognitive Distortion Categorize the ANTs Alternate Thought
Catastrophizing
Emotional Reasoning
Over-generalization
All-or-Nothing
Minimization of the Positive
Mind Reading
Jumping to Conclusions
Mental Filter
Control Fallacy--Overcontrol
Control Fallacy—Lack of Control
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34. CBT-CP—Cognitive Distortions Log
Automatic Negative Thought Alternate, more helpful thought
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People maintain a log of their ANTs and their disputes
Review the helpful thoughts at the beginning and end of each day.

35. CBT-CP
 Cognitive Strategies
 Challenge the negative thought by asking
Is this 100% true and factual?
Am I using automatic negative thoughts (ANTs)?
Is there a different way to look at this issue?
What would I tell a close friend if they had this thought?
Is this thought helpful to me?
Is there evidence that I am not taking into account?
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36. CBT-CP
 Cognitive Strategies
 Motivational Enhancement
Feedback
Responsibility
Advice
Menu of Options
Empathy
Support
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37. Summary
 Cognitive Behavioral Therapy addresses both thoughts and
behaviors
 Help people learn
 About their body and pain
 How over or under activity can make their pain worse
 About sleep hygiene and the importance of sleep
 What aspects of their pain they can control
 How pain impacts mood and vice versa
 Relaxation strategies
 Alternate, nonpharmacological, methods to address their pain
 Identify cognitive distortions and help people develop
alternate helpful thoughts
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38. Impact of Drugs
 Serotonin
 High or low serotonin can cause agitation, restlessness,
anxiety, irritability
 Low serotonin is associated with lower pain threshold
 Norepinephrine
 High norepinephrine can cause agitation, restlessness,
anxiety, irritability
 Reduces GABA
 GABA
 Enhances serotonin
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39. Treatment Options
 NSAIDS
 Opioids
 Tramadol/Ultram
 Narcotic
 Blocks pain receptors
 Releases serotonin and norepinephrine
 Topical analgesics
 Muscle relaxants
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40. Treatment Options
 Adjuvant analgesics
 Antidepressants increase serotonin and norepinephrine:
duloxetine/Cymbalta; venlafaxine/Effexor; nortriptyline/Pamelor
 Anticonvulsants (increase GABA), primarily used to relieve
neuropathic pain, include gabapentin, pregabalin/Lyrica,
topiramate, and lamotrigine
 Headache Analgesics.
 Preventative (e.g., Propranolol (beta blocker), topiramate (GABA))
 Abortive (e.g., Sumatriptan (Serotonin))
 Rescue (butalbital(GABA)/acetaminophen/caffeine).
 Rebound headaches, may occur when excessive analgesics are
taken for headache relief, leading to chronic daily headaches of a
different type.
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41. Treatment Options
 Nerve blocks
 Trigger point injections
 Radiofrequency ablation—High heat that destroys
nerves ability to transmit pain
 Botox (exp. For migraines)
 Spinal cord stimulator
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