Contextual Cognitive Behavioral Therapy for Chronic Pain

With the increasing emphasis on nonpharmacologic therapies for people with chronic pain, psychological interventions have received a substantial amount of research and have demonstrated value in this population. A number of studies support the effectiveness of cognitive behavioral therapy (CBT) for these patients, and there has been a greater focus recently on “contextual” forms of CBT. Conventional CBT aims to change dysfunctional thoughts, feelings, and beliefs, whereas contextual forms of CBT that include acceptance and commitment therapy (ACT) and mindfulness-based therapies, focus on “changing the influence of these experiences on a person’s behavior to improve overall quality of life,” according to a recent systematic review on the topic.¹

Mindfulness-based interventions have been linked with reductions in pain, disability, fatigue, pain-related catastrophizing, and pain self-efficacy.^2,3 ACT, which encourages patients to “act in line with meaningful goals and values while maintaining awareness and acceptance of thoughts and feelings,” has been found to increase pain acceptance and functioning while reducing anxiety and depression in adults with chronic pain compared with controls and other interventions.⁴ Although ACT includes aspects of mindfulness, some other approaches are based primarily on mindfulness — for example, mindfulness meditation and mindfulness-based cognitive therapy.

The American Psychological Association has identified ACT as having strong research support for use with various types of chronic pain. “For ACT, the purported mechanism is psychological flexibility, or the ability to behave consistently with one’s values even in the face of unwanted thoughts, feelings, and bodily sensations,” explained Niloo Afari, PhD, professor of psychiatry at the University of California, San Diego, and associate chief of staff for mental health at the VA San Diego Healthcare System, in an interview with Clinical Pain Advisor. This skill is developed through changing the ways in which one relates to internal experiences vs trying to reduce their form or frequency. “Thus, decoupling one’s internal experiences, such as pain and sadness, from one’s behavior, such as persisting in completing a painful task, will allow the values-driven behavior to occur.”

The goal of ACT is to reduce the impact of pain on functioning by increasing patients’ awareness of other important parts of their lives (termed “values” in ACT), according to Kevin E. Vowles, PhD, associate professor and area head of health psychology at the University of New Mexico, Albuquerque. “ACT hypothesizes that if pain cannot be eliminated, perhaps engagement in valued activities can be increased,” he told Clinical Pain Advisor. “While that is an imperfect solution, as pain continues, getting some meaning back in life is possible and often worthwhile.”

Although results pertaining to contextual CBT for chronic pain are promising, factors that predict or moderate outcomes of these approaches have yet to be elucidated. In a recent systematic review that examined these variables across 20 longitudinal studies, the researchers were unable to draw substantive conclusions because of pervasive methodologic limitations, especially heterogeneity in treatments and lack of basis in theoretic models.¹ Although they did find some evidence that baseline emotional functioning may be a predictor of treatment response, such results were mixed. For example, lower baseline depression and anxiety predicted better outcomes for pain-related interference in a randomized controlled trial of 238 patients, but no such link was found in another randomized controlled trial of 40 patients.^5,6

Among many remaining research needs, including additional studies to test the efficacy of contextual CBT in patients with chronic pain, there is also a need to “determine what adequate training for practitioners is needed for them to provide the interventions with accuracy and fidelity,” added Dr Vowles. In addition, it would be helpful to “work towards dissemination of findings to other settings — from tertiary care to primary care, for example — and translation of findings from research settings into everyday clinical practice.”

Dr Afari added that there is much to be clarified in terms of which approaches and components work best for certain patients, and under which treatment conditions. “More specifically, there is more work to be done to examine mechanisms underlying the impact of these therapies at multiple levels, such as behavioral concepts like psychological flexibility, as well as biomarkers,” he said. In addition, in light of research findings “indicating that ACT is also effective in addressing substance use disorders, studies examining the use of ACT to reduce opiate use in [patients with] chronic pain may be a good direction.”

While researchers continue to explore the underpinnings of contextual forms of CBT, Dr Afari suggested that clinicians who are interested in integrating these approaches into practice can start by reading books on the topic, attending trainings, and seeking consultation from other practitioners who have experience with ACT or mindfulness-based therapies. “These therapies have a very heavy experiential component, so just reading alone will not be enough. Most providers will need to go to some trainings and experience the work.”

Dr Vowles recommended asking patients about important areas of their lives that have suffered because of the pursuit of pain control and introduce values into the discussion as one possible treatment objective. “For too long, I believe we have placed reduction of pain intensity as the only goal of pain treatment,” he said. “For some, pain reduction does not seem possible and its pursuit can come at an incredible cost.”