DEAR DOCTOR K:
My doctor suggested cognitive behavioral therapy to treat my chronic back pain. Does he think I’m imagining my discomfort?
I’m often asked this question about cognitive behavioral therapy (CBT). Because it was developed by a psychiatrist and involves “talk therapy,” people assume that it is used to treat just psychological problems.
Not so. CBT can help people cope with many chronic “physical” illnesses. The symptoms caused by physical illnesses can generate anxiety and irrational fears. These, in turn, can make the pain worse.
Low back pain is the second most common cause of disability in the United States. Yet even though back pain is so common, not all people respond in the same way to this often-disabling condition. These differing responses are due in part to different people’s attitudes and outlooks.
Don’t misunderstand; I’m not saying you are imagining your pain. But psychological factors can influence your pain. I spoke about this with my colleague Dr. Srini Pillay, assistant professor of psychiatry at Harvard Medical School.
Pain itself can rewire your brain as well. When pain first occurs, it impacts your pain-sensitivity brain circuits. But lasting pain switches brain activity away from pain circuits to circuits that process emotions. That’s why emotions like anxiety often take center stage in chronic back pain. And it’s why emotional control becomes that much more difficult.
The good news is that CBT and mindfulness training can really be helpful for chronic back pain. Researchers recently published a landmark study that strongly supports the use of these therapies.
The researchers showed that training people with chronic low back pain in either mindfulness or CBT worked significantly better than medical care alone to reduce both their disability and pain-related suffering. What’s more, this greater improvement was still evident a full year later, when the study ended.
Mindfulness training teaches us to be aware of, and accept, moment-to-moment physical sensations of discomfort. At the same time, it teaches us to let go of our usual negative reactions.
CBT takes a somewhat different approach. It helps us learn to observe and identify our negative thoughts about our condition and replace them with more realistic and positive ones.
I often write about CBT, largely because my readers ask about it. In my professional lifetime, it is the most important new form of talk therapy. Studies have shown its effectiveness. The evidence is convincing enough that the doctor who developed the technique was honored with one of the most prestigious prizes for medical research, the Lasker Award.
Indeed, when I graduated medical school, the most prestigious form of psychiatric talk therapy was psychoanalysis, the technique developed by Sigmund Freud. CBT is increasingly used to treat psychological illnesses, and psychoanalysis seems less widely practiced. Particularly in the treatment of chronic physical illnesses, like low back pain, CBT has become a very important form of treatment.