Psychotherapy vs. CBT for Chronic Pain

Pain can have a profound social and psychological impact on those who suffer from it, and also those who care for them. What can you as a counsellor, psychotherapist, or psychologist do for such a client? While “talk therapy” admittedly does not always have the same quick response time as, say, painkilling medication, it can be hugely effective in helping the chronic pain client to come to a place of acceptance, opening the door to the establishing of a new life: one which accommodates the changes that have occurred.

We look at both psychotherapy and cognitive therapy, including under the latter’s umbrella the myriad techniques for working with one’s mind and attention to change the relationship with pain.

Psychotherapy: Getting at the roots of the pain

Even the most conservative of medical practitioners are coming to acknowledge the close interaction between our body and our thoughts and emotions. Yet chronic pain clients are often reluctant to explore the possibility that their pain has an emotional root. Part of the stigma we named above manifests in sufferers’ fear that they will be accused of making up the symptoms or causing them on purpose, yet that is not how true somaticising works. The pain is real, and often results from unexpressed emotions literally frozen or stuck in the body. Emotions release large amounts of chemicals into the muscles and organs, and the longer they stay there, the more pain and problems they cause; the pain is just as real as any caused by a medical condition.

Too, people tend to dislike acknowledging, even to themselves, that their pain may be psychogenic, because doing so deprives them of the hope that there will be a medical cure. Instead, if the pain is psychological in origin, they must face the challenging emotions that they avoided dealing with in the first place: the ones that caused the pain. Doing this generally provides relief in both short term and long term. Unfortunately, however, if the emotions have been held for a very long time in the body, they become primarily physical symptoms, and in this case even with catharsis, chronic pain may not go away (, 2013).

In addition to working with emotions, you have the possibility of helping chronic pain clients via a powerful tool: their minds, focused appropriately through cognitive therapy.

Cognitive Therapy: Retraining the mind and refocusing the attention

Cognitive Therapy and its associates Cognitive Behaviour Therapy (CBT) and REBT (Rational-Emotive Behaviour Therapy) place thoughts and their attendant emotions at centre stage of a person’s potential for wellbeing. While sessions of psychotherapy are looking into clients’ past to explore how “unfinished business” with others and unexpressed emotions are driving pain from underground, the cognitive therapies help people to discover which thoughts (and consequent emotions) in the here-and-now are causing pain and impairing clients’ ability to live as fully as possible given the illness or injury they may have.

Changing the way a person thinks may not render him or her pain-free, but this sort of therapy shows people how to change their relationship to pain, reducing it and becoming less affected by it, thereby enhancing a person’s effectiveness in their various life roles. If you are using any sort of cognitive therapy with a chronic pain client, you are likely to be helping the person learn to cope with their lives and their pain by teaching them:

  1. To think more realistically about their pain and other life phenomena
  2. To relax more deeply than they did before
  3. To manage their activities given their pain
  4. To solve problems related to their pain and other life stresses (Winterowd, Beck, & Gruener, 2003).

You would be likely to start with a focus on pain management and move from there to other issues or concerns. The primary target for change is the client’s negative and unrealistic thoughts, images, and emotions about their pain, the consequences of having it, and other stresses. We turn now to coping techniques enhancing your client’s capacity for positive, realistic, compassionate self-talk and beliefs.

Working with unhelpful thoughts

Even if you have only had minimal training in the cognitive therapies, you know that people shape their lives by the beliefs, thoughts, and expectations that they hold. Thus Albert Ellis’ ABC Paradigm, emanating from REBT, can be enormously helpful to people in pain. You can explain how people, contrary to what they may believe, do not go directly from “A”, the Activating Event (the trigger: let’s say a strong sensation of pain), to “C”, the Consequence: a consequent strong emotion (let’s say, despair at being in pain). Rather, the emotion is mediated by a “B”, or Belief (possibly, a thought such as that “I shouldn’t have to deal with this. I’ll never feel better”) (Ross, 2006).

To help clients identify ABC chains that they might have been unconsciously creating which are causing them pain, you may encourage them to start identifying their “C”s: the consequent strong emotions that arise from (often) out-of-awareness “Bs”: beliefs which are unhelpful, unrealistic, and often based on rigid thinking, with some sort of “should” or “must” attached to them.

Ellis later added a “D”, which stands for Disputation (Ross, 2006). In order to correct an unhelpful ABC chain, a person looks to dispute the rigid, unrealistic belief it is based on and replace it with a more realistic, flexible, compassionate stance (in the example we are following, the thought that the pain will go on forever can be replaced by, say, the thought that “I can manage my pain by managing my thoughts; it is time to employ one of my pain control techniques”).

Distraction and attention: Closing the pain pathways

Managing cognitions by actively replacing limiting ones is a solid tool for pain clients to use, yet there are also other ways clients can manage pain through managing their minds. The following three facts, taken together, constitute a strong case for distracting oneself from pain by merely putting attention elsewhere.

1. Focusing on pain means more pain. As we noted in examining the relationship between pain and the central nervous system (above), the way we focus our attention has a lot to do with how much pain we experience. This is because every sensation of pain which registers on our consciousness sends a signal through our pain pathways.

The more signals we send (i.e., the more thoughts focusing on our pain), the more pain receptors our nerves create to handle all the signals. The more receptors we have, the more sensitive our nerves become, leading to Central Nervous System Sensitisation. The more sensitivity we have, the more pain we experience. The more pain we experience, the more pain thoughts we have, in a vicious maintaining cycle (Chronic Pain Australia, 2013).

2. Attention is finite. You can help your clients to interrupt the cycle. Get them to think about it like this. Each of us has a finite amount of attention to give to our various life experiences. The more we give to one area, the less attention there is available for other areas. Putting major amounts of attention onto one’s pain, therefore, means much less attention for anything else. By inserting pleasurable experiences to our life, we increase our production of the so-called “feel good” chemicals – the neurotransmitters – such as the endorphins. With a high percentage of attention on our enjoyable experiences, we are emotionally and chemically reducing our pain (Chronic Pain Australia, 2013).

3. Attention is like a muscle: it can be strengthened by using it, and it can be directed to do the “heavy lifting” in whatever direction we require. Therefore, the name of the game in pain control is “attention enhancement”: growing the capacity for attention and then directing that newly enhanced capacity to those experiences that generate “feel-good” (i.e., pain inhibiting) chemicals, thus limiting or closing the pain pathways formerly experienced.

This means that we help clients control their pain when we help them to distract themselves from the pain – reducing pain signals – and add in enjoyable sensations and experiences, facilitating the production of pain-inhibiting endorphins. When we help them grow their capacity for paying attention, they are even more powerful at regulating these processes.

This article was adapted from the Mental Health Academy course “Managing Chronic Pain”. The purpose of this course is to give you, a counsellor, psychologist, or psychotherapist, a basic understanding of chronic pain, and how to help manage it, whether your client is an individual suffering from it or a caregiver supporting someone who does.


  • Chronic Pain Australia. (2013). Helpful thinking. Chronic Pain Australia. Retrieved on 3 June, 2013, from: hyperlink.
  • (2013). Chronic Pain. Retrieved on 22 May, 2013, from: hyperlink.
  • Ross, W. (2006). What is REBT? REBT Network. Retrieved on 3 June, 2013, from: hyperlink.
  • Winterowd, C. L., Beck, A.T., & Gruener, D. (2003). Cognitive therapy of chronic pain. Academy of Cognitive Therapy. Retrieved on 21 May, 2013, from: hyperlink.