Chronic pain (CP) is more than just a physical difficulty, it is something that can affect a patient’s emotions, behaviours, and mind. It can lead to feeling overwhelmed, frustrated, hopeless and isolated which may impact overall quality of life. CP is known as recurrent and persistent pain lasting for three months or longer and the severity of pain can vary in terms of functional impairment, intensity, and pain-related distress. It is a common and often debilitating difficulty in physical rehabilitation settings.
Whilst physical interventions such as physiotherapy and medication play a vital role in treatment of CP, they are often not enough on their own. Cognitive Behavioural Therapy (CBT) offers a powerful, evidence-based approach that can be used alone or in combination with physical interventions. It helps patients to improve psychological and emotional well-being as well as functional outcomes by changing how they think and respond to pain. The goals of CBT focused on CP is to reduce the negative impact of pain on daily life, to feel more confident in one’s ability to manage pain, to rethink unhelpful thoughts and be less fearful about pain, to improve physical and emotional functioning, to increase effective coping skills for managing pain, to reduce the intensity of pain and to develop and enhance skills that help to find balance and avoid flare-ups. CBT has a wide range of techniques and tools used to achieve these goals, five of which are discussed below.
- Provide psychoeducation on pain and factors that affect pain.
Creating a safe environment to discuss and provide psychoeducation on pain and factors that affect pain is a therapeutic intervention that enhances motivation, understanding, emotional resilience and behavioural change – all of which are vital for meaningful recovery in rehab. Helping patients understand what pain is—and the purpose it serves—can reduce fear and promote a healthier relationship with their experience. Importantly, recognising that pain is not purely a physical sensation, but one that is influenced by a range of factors, empowers patients to take a more active role in managing it. These influencing factors can include physical elements (such as injury or muscle tension), cognitive patterns (like negative thoughts or unhelpful beliefs), emotional states (such as anger, anxiety, or low mood), behavioural responses (like activity avoidance), and social influences (including isolation or limited support). By increasing awareness into these contributors, patients are better equipped to use practical strategies to manage their pain more effectively and resume a sense of control and confidence in their recovery journey.
- Setting SMART goals
Setting goals helps patients clarify what they want to achieve, making progress feel purposeful and possible. Goals that are Specific, Measurable, Achievable, Relevant and Time-bound turn hope into action. They provide clarity, structure and encouragement that help patients to reclaim agency, stay motivated and measure progress – no matter how small the goals may seem. The SMART goals may be related to managing pain, understanding pain, changing thoughts, behaviours or emotions or progressing in the rehabilitation journey.
- Engagement in activities and the use of pacing
Engaging in activities that the patient enjoys supports emotional and mental health by improving dopamine and serotonin levels and regulation thereof. This engagement may increase self-esteem, confidence and improve energy levels. Participating in activities that one enjoys restores a sense of normalcy and routine helping to rebuild structure and autonomy. Scheduling pleasant activities that are manageable, using tools such as goal-setting worksheets or scheduling worksheets will allow patients to feel empowered, engage in positive activities and track their progress. However, learning to balance activity and rest, whilst engaging in activities will reduce flare-ups, allow for progression, and improve consistency. This concept of pacing – avoiding overdoing it on good days and underdoing it on bad days – involves balancing various activities, planning and engaging in moderate, safe activities on a regular basis.
- Relaxation training
Chronic pain is often accompanied by anxiety, autonomic arousal, and muscle tension. Relaxation techniques and training reduces physiological stress responses which promotes better sleep, emotional regulation, and overall well-being. Engaging in relaxation techniques aids by calming the nervous system and easing pain perception. Techniques may include mediation, deep breathing or progressive muscle relaxation which helps patients to focus on the present moment, reducing anxiety and fear linked to pain. These techniques can be used in psychotherapy sessions, physiotherapy sessions, various other types of sessions or independently to manage distress or flare-ups.
- Cognitive Coping
Negative thoughts and unhelpful thinking patterns may worsen emotional distress, trap patients in cycles of fear and avoidance and increase perceived pain intensity. Identifying and challenging negative thoughts and unhelpful thinking patterns allows patients to feel more confident, have greater control over their circumstances and their emotions and promotes a stronger engagement in the rehabilitation process. Helping patients identify and recognise their negative thoughts is the first step toward meaningful change. Once these unhelpful thinking patterns are brought into awareness, they can be gently questioned and evaluated — are they accurate, realistic, or helpful? If not, they can be reframed into more balanced and constructive alternatives. For example, the thought “There’s no point in trying” might be replaced with “Even small steps can help me improve and feel more in control.”
By integrating these CBT techniques into physical rehabilitation, not only will patients be able to manage their CP better but also shift from passive sufferers of pain to active participants in their own recovery. Not only will they build physical strength, but also resilience, confidence, and control over their lives.
For more information on what CBT is, check out our previous blog here: https://charispsychology.co.za/category/cbt/
For more detailed information on CBT for CP, check out this patient guidebook: https://www.va.gov/PAINMANAGEMENT/CBT_CP/docs/Brief_CBT-CP_Patient_Guidebook-4-13-2021.pdf