Week 1: Understanding chronic pain

Week 4: Healthy thinking, healthy self

Week 5: Balancing your activity patterns

Week 6: Maintaining your gains and staying well

A CBT model of chronic pain

CBT offers us a way of understanding your pain experience in all its forms. It is a way of looking at what is going on for you and how your thoughts, feelings and behaviour interact with each other, and your pain. It also helps to highlight the areas that are important for you to work on throughout this course and beyond. Below, we present a CBT model of chronic pain and discuss some relevant examples. If these examples don’t fit your own pain experience perfectly, see if you can identify with certain elements of the example and extrapolate to your own circumstances.

As you can see from the diagram, your pain interacts with your thoughts, feelings and actions in a bidirectional manner. In other words, the relationship between these factors goes both ways. It is important to understand this connection, as it will form the foundation for many of the pain management strategies we introduce in this course. For example, your behaviour might trigger your pain, such as when lifting something causes lower back pain to flare up. Similarly, your pain can influence your behaviour, such as when you avoid moving for the remainder of the day. 

Likewise, your thoughts can influence your pain and vice versa. Pain may trigger thoughts like “My day is ruined” or “I can’t cope with this”, whilst these types of thoughts can also worsen your pain. Research has shown that catastrophic thoughts can intensify and prolong pain. Similarly, catastrophic thoughts often lead people to feel hopeless and frustrated. Such emotions also make people more sensitive to pain. In turn, pain can negatively impact people’s mood and emotions, further discouraging them and adding to their irritability. 

As you can see, this creates a negative feedback loop, which maintains pain and keeps people stuck. The good news is that this model gives us insight into a variety of ways to manage pain. In CBT, it is assumed that the entire feedback loop can be modified by targeting a single factor. For example, your pain experience can be altered by changing the way you think, behave, or manage your emotions and/or physiology. Making changes in all three areas is likely to have the most benefit. To demonstrate this further, let’s meet Mikala.

Example: Mikala 

Mikala started suffering from chronic pain following a sports injury just over a year ago. Mikala’s pain is mainly in her neck and shoulders. She also experiences fatigue and frequent headaches as part of her condition. Over time, Mikala has become hyper-aware and focussed on her pain. We will discuss the reasons for this ‘hypervigilance’ later in the course, but it is not uncommon for people with chronic pain to experience this. When Mikala becomes more aware of her pain, she becomes fearful and reduces her activity to avoid making it worse.

As a result of her reduced activity, Mikala has lost fitness and muscle strength. She also has difficulties with sleep and has lost confidence in her own abilities. This causes Mikala to withdraw even more from her usual activities. When she does re-engage in activities, Mikala’s performance is lower than it used to be, which causes her to be self-critical. Sometimes, in an attempt to meet her own high standards, Mikala will push herself to ‘do better’. In doing so, she overexerts herself, which leads to even longer periods of inactive recovery. 

All of this results in feelings of frustration, sadness, loss of control, helplessness, anxiety and low mood. These emotional states worsen Mikala’s pain and other symptoms, including her headaches and poor sleep. Increased periods of inactivity also mean Mikala has little distraction from her symptoms, unhelpful thoughts and worries about not doing well enough in life. Mikala compares herself to her friends and colleagues, and feels inferior. Mikala wants to be more active, yet she believes that increasing her activity will worsen her pain and leave her immobile. 

When you understand how your symptoms are being maintained by your thoughts, feelings and behaviours, you can take steps to intervene. For example, by reducing her activity and worrying about her performance, Mikala actually worsened her symptoms. These behaviours led Mikala to lose muscle strength, feel stressed and tense in her body, and lose confidence in herself. Stress and tension held in the body is a sure way to worsen pain. If Mikala changed this behaviour, she may have found some symptom relief. This would also have had a flow on effect to the way she thinks and feels. 

Similarly, by practicing relaxation techniques, Mikala could reduce her anxiety and physical tension. Instead of thinking negatively, Mikala could be more balanced in the way she talks to herself. She could tell herself encouraging things like, “I’m doing my best, that’s good enough” and “Activity isn’t the enemy, I just need to find the right balance”. This may help Mikala approach activity gradually, rather than avoid it completely. It may also directly improve her symptoms by reducing her body’s stress response (more on this next week).

Before moving on, have a think about your own experience of pain and see if you can break it down into the various parts of the CBT model. How does your pain show up? What thoughts and emotions accompany it? And how do you tend to respond to it (i.e. what do you do)? You may not know all the answers yet, but see if you can identify at least some pieces of the picture. Try drawing your own CBT model of pain on a piece of paper. You can add to this diagram as you gain more insight throughout the course.