This document provides an overview of cognitive behavioral therapy for chronic pain (CBT-CP). It discusses the core targets of CBT-CP which include exercise, pacing, relaxation training, cognitive restructuring, behavioral activation, function and values, and sleep and diet. It also covers psychological factors like cognitions, catastrophizing, suffering vs. pain, hurt vs. harm, negative affect, answer-seeking, and pain self-efficacy. Behavioral factors like passive coping, resting/inactivity, exercise, and over activity are examined. The document provides guidance on pacing and relaxation training. It also touches on social factors patients with chronic pain may face and provides a case conceptualization example.

1. CBT FOR CHRONIC PAIN –
CBT CP
Developing a CBT
treatment plan and short-
term treatment.

2. CORE TARGETS OF CBT-CP
Exercise: Increased engagement in valued physical activities
Pacing: Activities that grow stamina/strength with in
window of tolerance
Relaxation Training: Development of skills to relax and
reduce stress
Cognitive Restructuring: Changing ANTs, Challenging Core
Cog
Behavioral Activation: Enhanced pleasurable and
meaningful activities
Function and Values: Increased values based living
Sleep and diet: Improving sleep and diet to address pain

4. PSYCHOLOGICAL FACTORS: PAIN
COGNITIONS
Pain cognitions are thoughts and beliefs that lead to
increased suffering, increased pain perception/signal,
disability and maladaptive coping.
What are some common pain cognitions that
could be dysfunctional?

5. PSYCHOLOGICAL FACTORS:
OVERVIEW
Catastrophizing: One of the core aspects of thoughts
that lead to increased pain, ineffective pain coping,
and increased distress.
Suffering vs Pain: Suffering is the emotional response
to pain. Pain is the specific sensation.
Hurt versus Harm: Pain is supossed to be a signal of
harm. In chronic pain, pain itself is a disease and no
longer is a clear indication of harm. The ability to re-
interprate pain as harmful vs hurtful can impact pain
functioning.

6. PSYCHOLOGICAL FACTORS:
OVERVIEW
Negative Affect: Depression, Anxiety and Difficult
emotions can happen when we are in intense pain.
This can increase pain intensity, poor coping and acts
like a volume knob turning up pain.
Answer-Seeking: Difficulty accepting the ambiguity of
a pain diagnosis and continuing to try to find an
answer when acceptance and engagement w/ tx would
help more. Often related to grief process.
Pain Self-Efficacy: An adaptive belief that an individual
has developed some ability to manage, accept and
control the impact of pain on their life.

7. PSYCHOLOGICAL FACTORS: PAIN
COGNITIONS

8. BEHAVIORAL FACTORS: CHRONIC
PAIN
Passive Coping: Coping that is passive in nature and relies
passive strategies.
 Guarding: Any postural attempts at management that include
bracing, limping, protection of limbs. These can be
unconscious, semi-conscious or conscious patterns used to
protect an area that has been in pain.
 Resting/Inactivity: Resting is vital for effective pain
management. This can become the dominant strategy for pain
management. If this happens it leads to deconditioning
emotionally, physically and increased avoidance.
What are some ways you can think of to help address these
strategies?

9. BEHAVIORAL FACTORS: CHRONIC
PAIN
Active Coping: Coping that is physically active in nature.
 Exercise: This is a potentially positive activity that helps
individuals increase tolerance for pain, increase conditioning
and reduce overall pain levels?
 Over Activity: Over activity can lead to feelings of overwhelm,
giving up, increased pain and reduces the positive impact of
pain interventions.
Can you explain why exercise helps with chronic
pain?

10. PACING AND PAIN: BRAKING THE
CYCLE

11. BEHAVIORAL FACTORS: CHRONIC
PAIN
Pacing: As previously mentioned, pacing is the practice of
engaging in an appropriate level of physical activity without
significantly exacerbating pain. By using calculated increases in
activity, pacing can lead to greater endurance and a reduced
frequency of intensely painful episodes.
Relaxation Training: Relaxation techniques lead to decreased
perceptions of pain and can contribute to feelings of self-
efficacy to manage pain.
What are some ways you have found to provide
effective relaxation training?

12. SOCIAL FACTORS: CHRONIC PAIN
Let’s generate a list of common
social factors our patients face
related to chronic pain

14. CASE CONCEPTUALIZATION
REGGIE: Reggie is a 64-year-old, African-American male Vietnam Army Veteran
with bilateral foot pain due to diabetic neuropathy. He also has joint pain in his
knees and ankles. His primary care physician referred him for assistance with
how he can better manage his pain. Reggie was diagnosed with diabetes 9 years
ago but the painful tingling and numbness in his feet has worsened over the last
2 years. He is now mostly sedentary and spends most of his day watching
television in his recliner. While he was overweight when diagnosed, he is now
morbidly obese and has gained 30 pounds this year. His provider shared that
Reggie has not taken his pain medications consistently, and has discontinued
physical therapy after one session since it created increased pain. Reggie is
frustrated and angry about his lack of mobility and need to use a rolling walker
when walking long distances. He has been married for 35 years and describes
his wife as an “angel;” however, he feels guilty that he is unable to help more
around the house and with yard work, and reports that he “snaps” at her because
of his pain. He wants to be able to play with his grandchildren and be more

15. CBT-CP SESSION GUIDE: STEP BY STEP
Make Practice/Homework Plan
Problem Solve Skills in Life
Develop Skills/Education/Training
Develop and Agreed Agenda
Assess SUDS and Functioning

16. Assessment
Reconceptualization of Pain
Skills Development
Rehearsal of Skills
Enhance Maintenance
Follow Up and Relapse Prevention
TREATMENT ARC AND GOALS: CBT-
CP