Alex Simotas, MD

Hospital for Special Surgery
Board Certified Physiatrist
Specializing In Spine & Sports Medicine

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Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is a form of psychological therapy that can be used to treat chronic back pain. Many well-designed studies have shown the clinical effectiveness of CBT. Thoughts are the “cognitive” part, and actions are the “behavior” part of Cognitive Behavioral Therapy. Treatment often involves dedicated meetings with a trained therapist.

How Does CBT Work?

Our thoughts and beliefs about pain may play a central role in how we are conditioned to feel pain. These beliefs also form the basis of how we direct ourselves to behave and move in response to pain or the potential or perceived threat of pain. Of course these thoughts and beliefs can be influenced by your prior experiences, your peers, and the professional advise you receive. In addition, emotional factors such as fear and frustration can influence our thoughts and beliefs. The premise of CBT treatment is that these beliefs are often negative “distortions” that can be identified and replaced with more rational and positive beliefs. Some thoughts may be distortions. Distortions are beliefs that are slightly or greatly twisted towards a more negative interpretation. Other thoughts and beliefs are purely misinterpretations of a condition.

An example of an incorrect belief is the idea that one should avoid all activities that cause back pain. A more correct belief is that activity and exercise do not cause harm or injury. Avoidance of activity can lead to deconditioning which can worsen back pain problems.

Here is list of some of the “classic” distortions that are identified in traditional CBT [From: Burns, David D. Feeling Good. Morrow, 1980. A Word About Identifying Incorrect or Distorted Beliefs].

  • ALL-OR-NOTHING THINKING: You see things in black and white categories. You may be “cured” or a total failure.
  • OVER GENERALIZATION: You see a single negative event such as an episode of back pain or a previous injury as a never-ending pattern of defeat.
  • MENTAL FILTER: You pick out a single negative detail and dwell on it exclusively so that your vision of all reality becomes darkened, like the drop of ink that discolors the entire beaker of water.
  • DISQUALIFYING THE POSITIVE: You reject positive experiences by insisting they “don’t count” for some reason or other. In this way you can maintain a negative belief that is contradicted by your everyday experiences.
  • JUMPING TO CONCLUSIONS: You make a negative interpretation even though there are no definite facts that convincingly support your conclusions. You may believe your back pain will never go away.
  • MAGNIFICATION (CATASTROPHIZING) OR MINIMIZATION: You exaggerate the importance of things (you are convinced that one trip or fall may have ruined your spine again).
  • EMOTIONAL REASONING: You assume that your negative emotions necessarily reflect the way things really are: “I feel it, therefore it must be true.”
  • SHOULD STATEMENTS: You try to motivate yourself with shoulds and should nots. The emotional consequence is guilt, anger, frustration, and resentment.
  • LABELING AND MISLABELING: This is an extreme form of over-generalization.

Instead of describing your error, you attach a negative label to yourself: “I have degenerative disc disease.”

The success of this form of therapy greatly depends on the experience of the therapist in helping you identify what thoughts are actually incorrect. Often a well-trained psychotherapist will be unfamiliar with musculoskeletal medicine. More successful CBT based programs are part of a multi-disciplined treatment where musculoskeletal physicians can help redirect patient beliefs and activity with the assistance of a CBT therapist. An example of how this might apply is changing a negative thought, such as “I can’t do anything anymore,” to a more positive thought, such as “I dealt with this before and I can do it again.” This concept draws on some thought changes that are based on a pain management theory. In this case it is assumed that the patient has previously had treatments, which were correctly directed so the patient is reminded that some (not permanent or more successful) pain relief can be expected.

A more multidisciplinary CBT response would include positive thoughts such as “I have a new strategy and understanding of how to respond to my pain… this will help improve how I experience the pain and help me improve my physical conditioning.”

A therapist using CBT will help you learn to:

  • Identify negative thoughts
  • Stop negative thoughts
  • Practice using positive thoughts
  • Develop healthy thinking

Healthy thinking involves positive thoughts. It also involves calming your mind and body using techniques such as yoga, massage, and imagery. Healthy thinking makes you feel better, and feeling better reduces pain. CBT can also teach you to become more active. This is important because regular low-impact exercise, such as walking and swimming, can help reduce back pain over the long run.

For CBT to help reduce pain your treatment goals need to be realistic and your treatment should be done in small steps. For example, your goals may be to see friends more and start exercising. It is realistic to see one or two friends at first and take short walks, maybe just down the block. It is not realistic to reconnect with all of your friends all at once and walk 3 miles at once on your first outing.

A healthier, more rational belief system will improve the way you behave and lead to a desensitization and reduction of pain.

Successful treatment involves several basic steps

  1. Identify many of the “automatic” thoughts that you have about the pain problem
  2. Review how these thoughts may be either distortions or grossly misleading. It may be helpful to review the basic types of distortions (above)
  3. Replace these negative thoughts with more positive thoughts
  4. Review how you can implement a positive behavioral program (exercise and activity)
  5. Develop an activation plan of gradual activity changes.