Cutting Edge Psychology

Can CBT help with chronic pain?

Posted on January 28, 2013 at 6:20 AM


These are my personal views of CBT, based on my own experiences, observations, readings and research over the last 30 years. Like all other types of psychotherapy, CBT has been demonstrated effective for a range of psychological issues (research shows that 80% of people receiving psychotherapy are better off than people with the same problems who are not receiving it- and the choice of therapy makes no difference to this general outcome). Despite this 'as good as' status, many CBT practitioners have behaved as zealots, advocating that it is the one and only useful type of therapy- clearly not the case. Also, whenever another approach is found to be effective, it somehow gets captured under the CBT label, as though it is a variation when in fact it may be quite different in its epistemology, its basic assumptions and its method (I have read EMDR being referred to as 'CBT with a novel variation'). And some innovators will (i suggest) deliberately define their new approach as a variation of CBT in order to get some coat-tail credibility (e.g i think Hayes, who developed Acceptance and Committment Therapy- ACT- has done this, and demonstrated that it is a useful strategy- i think there are more differences between CBT and ACT, such that it is a different enterprise and CBT really cant legitimately claim it).


Now, when it comes to chronic pain, i observe that not all therapies are the same. CBT (in its form devised by Aaron Beck) at best can help people adjust to being in pain so as to decrease their catastrophising, black and white thinking ('my life is over'), etc. This is helpful, in that it can decrease the amount of emotional distress associated with chronic pain, and may lead to a decrease of the pain due to a decrease in emotional tension. In my book, i refer to an ex-client of mine who was not open to my approach, but did actually get over his pain via the standard CBT in a pain management program. This is (in my observation) unusual- it rarely happens. The more common reaction is a greater acceptance of being in pain. While any relief is welcome, i think its a bit like learning to live on your knees when you can in fact learn to walk again.


Sarno has used psychoanalyst Franz Alexander's model of chronic illness (derived from Freud's model of the psyche) and created a depth-psychology approach which is delivered in a cognitive-behavioural (psycho-educational) bottle. It is ironic, as 'cognitive-behavioural' does not usually sit in the same sentence as 'depth-psychology', unless they are presented as a juxtaposition.


Depth-psychology has a range of assumptions, an epistomology and sweep of methods which are in contradiction to cognitive-behavioural approaches (well, until Sarno- and some notable others- combined them). From all the people who get better just by reading Sarno's or my books, it is clear that this cognitive level change can result in decreases and even eradication of chronic pain. However, the type of cognitive and behavioural changes brought about by TMS books or information is not the type of cognitive-behavioural changes brought about by CBT. The TMS approach is utilising notions of the unconscious mind, and suggesting that symptoms serve a purpose to the unconscious. CBT (as per Beck) barely even acknowledges the existence of the unconscious, and give no causal role to it in generating symptoms- the focus is clearly on the stuff we are aware of. The change strategy is to dispute what we are telling ourselves with evidence about 'reality' which we gather, much like a scientist gathering evidence from research. On some levels, this is appealing- it is relatively 'clean', free of messy emotions and confusions, and it makes some intuitive sense. We all suspect that our thoughts play some role in our problems. However, its model of emotions (ie. they are derived from our thoughts) is demonstrably wrong, as evidenced by decades of research in neuroscience. As such, pure CBT practitioners are teaching clients a myth (their causal model of emotions), in the hope that it will generate therapeutic changes. The impression that i wound up with from practicing CBT and RET is that it was largely a placebo effect- it created an expectation of change, and often this would result. The real question is 'does it work with chronic pain?'. My answer is, generally, no.


If chronic pain is being generated by the unconscious mind/brain in order to protect us from threatening emotional material in the unconscious (our 'emotional truths'), then the most helpful approaches are going to be ones that acknowledge and utilize the unconscious. We know via success stories from TMS books that pure information (cognitive change) can help, but it needs to be information which is highlighting the role of the unconscious- not cognitive information which is focused on what we are consciously telling ourselves at a surface level. The TMS-book-cognitive-change will be helpful for many people, as all they need is to become aware (on a cognitive level) of what is going on to generate pain, and this creates an experiential shift which is deeper than the mere cognitive level. However, there are people for whom this is not sufficient- they need more than this level of change, and it appears that a depth-psychology therapy is what they need. The ones i am aware of are brief approaches to psychoanalytic therapy, EMDR, and Coherence Therapy (see under Addendums to the book under 'About the book').

Most contemporary psychologists are both uninformed and uninterested in utilising psychological approaches to healing chronic pain. This has resulted from three decades of CBT being the 'flavour of the month'- any notions of the unconscious have become viewed as anachronisms, and the depth psychology baby has been thrown out with the Freudian bathwater in preference to a focus on surface level thoughts and feelings. A depth-psychology focus is needed with chronic pain in order to go beyond the surface level, as the symptoms serve an unconscious emotional purpose. CBT barely even acknowledges unconscious thoughts/feelings, and has even less of an idea as to what to do with them. I would think that any psychologist or psychotherapist who utilises a depth-psychology approach, whether they have heard of Sarno/TMS or not, is in a better position to work with people regarding their chronic pain than most CBT practitioners. Those not utilising a depth-psychology approach (and i think this is most psychologists- certainly in Australia anyway, and i suspect in America too) can at best help people to adjust to the pain. This may be welcome, as any relief is better than no relief; but most people actually want to get over their pain, not just learn to accept it. Acceptance is really important though, and can provide some relief, but eradicating the pain is a viable goal as well. There are some signs of hope on the CBT horizon- ACT does entail some depth elements, and can be effective in helping to reduce chronic pain (although it is questionable how true to CBT it is? Have its founders simply called it a form of CBT in order to get their nose under the tent? Seems to be one of the few ways to get a new approach taken seriously these days).

Psychology as a profession clearly needs to go beyond a focus on the surface level and rediscover its depth-psychology legacy (ie. not just Freudian, but also the psychology of William James- the founder of psychology in America). My profession has failed people in chronic pain for the last 3 or so decades, and this needs to change. As such, one of the purposes of my book (The Hidden Psychology of Pain) is to bring TMS ('The Mind/Body Syndrome') theory into maintstream psychology, highlighting its points of confluence with other elements of contemporary psychology and neurology.

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