Pain is rarely, if ever, “all in your head” — but what’s going on in your head (and your life) probably does affect pain, because pain is weird.1 It makes sense that a little head doctoring might be helpful.
The goal of mainstream psychological therapy for chronic pain is usually framed not as an attempt to actually treat pain directly, but to help people “live a full life with confidence in managing that pain.”2 Despite that disclaimer, many a psychologist has suggested to their clients that better coping can lead to lower pain levels, which in turn makes it easier to cope. Wisely or not, mental health professionals do often aspire to treat pain indirectly via that virtuous cycle.3
So what does the data say?
The data says “hell no”
A comprehensive 2020 review was very negative.4 Nothing is ever the “last word” in this business, but this paper comes close. It’s the latest of several versions and “by far the biggest,” with data pooled from 9400 trial subjects in dozens of experiments.5 It was mostly about three related methods:
- cognitive behavioural therapy (CBT)
- behavioural therapy (BT)
- acceptance and commitment therapy (ACT)
The realm of mind-over-pain can be subdivided into many distinct but overlapping approaches, everything from meditation to hypnosis,6 but CBT, BT, and ACT are clearly the dominant mainstream approaches, and there wasn’t enough data about all other therapies combined to fill a bathtub, let alone a statistical pool with a deep end. So mostly this is about CBT and its cousins, ACT and BT — which seem different up close, but awfully similar from 20 paces away.
Cognitive behavioural therapy
CBT is the most studied type of psychological treatment by a wide margin, and it was found to have a “slight” benefit only, which is synonymous with a negative result. No one wants a dozen sessions of psychotherapy for a “slight” benefit. That is not a good return on investment. Ain’t nobody got time for that.
Interesting side note: CBT had terrific results in four papers. Those results were suspiciously good, and so they were excluded.7
It’s important to acknowledge that CBT is “technically” the leading evidence-based treatment for fibromyalgia (which is a more specific version of chronic pain: “a pattern of unexplained stubborn chronic pain, stiffness, fatigue, and mental fog”). There is probably more good quality evidence to support the efficacy of CBT for fibromyalgia than there is for any other treatment. Sounds good, right? But it isn’t saying much. If you read the fine print, it’s good evidence of a minor benefit: so minor, in fact, that the evidence of benefit “might not be clinically important to patients.”8 That’s a huge damned-with-faint-praise problem for CBT for fibromyalgia.
There was much less data on behavioural therapy (BT, minus the C-for-cognition). It wasn’t adequate for a strong conclusion, nor promising. The absence of a clear positive signal is a negative signal.9
Acceptance and commitment therapy
And the data on ACT is inconclusive, which is another kind of negative result.10 The authors suggest that ACT — which has a vibrant community of practitioners — “has been propagated less on evidence than on practitioner enthusiasm.” Because what else is there? They obviously cannot base it on evidence.
On the quality of the data
I do not believe that I have ever seen a review that didn’t point out that the evidence is just a sorry mess. In this case, “a large number of underpowered trials with poor evaluation practices raise concerns about research waste.”
I think we’re past the point where that’s just a “concern.”11 But, in this case, there was so much data on CBT that there were enough good-apple studies to work with, and so at least one clear negative conclusion was possible.
Psychotherapy is still useful
Chronic pain often goes hand-in-hand with depression, anxiety, stress, sleep deprivation, and addictions — all of the systemic vulnerabilities that are probably an underestimated part of the pain puzzle.12 And while “all in your head” is perhaps the most hated “diagnosis” there has ever been, of course psychosomatic illness/pain does exist, and hopefully psychotherapy can help with that too.
Psychotherapy can probably reduce the suffering and disability caused by pain, even if there aren’t any clear downstream effects on pain itself. But there still could be! Just because it doesn’t happen on average (which is all the research can detect) doesn’t mean it never happens. It might work quite well with a therapist who is both skilled and lucky enough in how they try to help; it might work with the right patient, with the right kind of pain.
Trying to work around the evidence by claiming that a treatment works for special people, missed by the research, is a common foul in the world of pain medicine, especially about back pain.1314 But psychotherapy is a dizzyingly complex intervention, lots of variables, that might help some people when all the variables are just right.
In any case, psychotherapy is like massage therapy: it can be a pleasant and rewarding experience regardless of whether it can achieve specific therapeutic goals for pain. Its other benefits are, hopefully, complex and numerous.
But mental health care professionals probably should stop trying to treat pain — directly or indirectly — and just focus on helping people any other way that they believe that they can.
CBT as “glorified toxic positivity” or gaslighting
CBT might be useful at its best, but that’s highly speculative. What is not so speculative is that it can backfire by effectively blaming the patient. But don’t take my word for it. Alana Saltz, a writer and disability rights activist, brilliantly explains how she soured on CBT. I’ve highlighted a few points that I think are particularly excellent:
I received CBT therapy for many years, starting as a kid. It was years of being told that my emotional and physical pain was an overreaction due to distorted thinking. I wonder what it would have been like to have my pain heard, acknowledged, and validated instead?
It turns out, unsurprisingly, that I had many chronic illnesses that were previously undiagnosed due to my age, doctor bias, and lack of research around conditions. I had also experienced significant traumas that were not adequately explored or addressed by those therapists.
Yet the gold standard, go-to is CBT for everything, including PTSD and chronic illness. Even if you have physical symptoms and diagnoses or have experienced trauma(s), your response to pain is still gaslighted out of you. You’re assumed to be “thinking about it the wrong way.”
In my experience, and I’ve had a lot of it, CBT can be glorified toxic positivity. It doesn’t allow for fear or grief around illnesses and traumas. It encourages potentially ableist remedies like “getting out more” and “being social” when that might make certain conditions worse.
I’m not saying this to give therapists a hard time. I’m saying this because I want there to be more awareness and research around new modalities that have the ability to acknowledge emotional and physical pain without making someone feel invalidated and gaslighted.
We need to make sure that therapists aren’t engaging in bias, the same bias that many medical professionals can fall into, that trivializes and dismisses physical pain and trauma that would benefit from different modalities of therapeutic treatment.
I now use my concerns about CBT when consulting with a potential new therapist. I was pleasantly surprised when one recently agreed with me and said that modalities like CBT are based around outdated ways of thinking about pain and illness. I hope that means change is coming.
About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter, or subscribe:
- Mind Over Pain — Pain can be profoundly warped by the brain, but does that mean we can think the pain away?
- Pain is Weird — Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues
- Anxiety & Chronic Pain — A self-help guide for people who worry and hurt
- Why Do We Get Sick? — The curious and tangled connections between pain, poor health, and the lives we lead
- Chronic Pain as a Conditioned Behaviour — If pain can be learned, perhaps it can be unlearned
- The Art of Bioenergetic Breathing — A potent tool for personal growth and transformation by breathing quickly and deeply
- Pain Relief from Personal Growth — Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness
- Chronic Pain and Inequality — The role of racism, sexism, queerphobia, and poverty in health and chronic pain
What’s new in this article?
2021 — Science update, added citation and discussion of Mascarenhas et al on cognitive behavioural therapy for fibromyalgia.
2020 — Added section, “CBT as ‘glorified toxic positivity’ or gaslighting.”
2020 — Publication.
- More specifically, because pain is a perception: that is, it is an interpreted sensation, modulated by our hopes and fears and beliefs about its implications. Pain is weird because it’s volume affected by our minds … and our minds are weird.
- EvidentlyCochrane.net [Internet]. Williams A. Managing chronic pain in adults: the latest evidence on psychological therapies; 2020 October 8 [cited 20 Oct 8].
This reminds me a little of the claim of “facilitating healing.”
The idea of facilitating self-healing is a cliché of alternative medicine. For example: “A healer just triggers your own ability to heal yourself.” It’s sacharine, silly, inspirational-poster nonsense. More technically, it’s a “deepity,” an idea that is either profound but wrong, or true but trivial. If healing actually could be “facilitated,” that would be miraculous.
Facilitated healing is touted to make someone seem like a “healer” without coming right out and saying it, a “humblebrag.” It sounds humble, but it isn’t. It also rationalizes therapy that does not have a clear or specific mechanism.
So what’s the connection with psychotherapy? It seems like a close cousin to “I’m not treating pain with psychotherapy, I’m just helping you treat it yourself.”
- Williams AC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020 Aug;8:CD007407. PubMed #32794606 ❐
I will lean heavily on this major review for this article. There are other sources and nuances to discuss, of course, but this is much more important than most.
- A few technical notes: “Mindfulness” was excluded, as was treatment for headache. Only professional face-to-face delivery was considered. The researchers shunned small studies to avoid “a higher risk of unrealistically positive results.” The analyzed 75 studies — more than double the last version — representing 9400 people, two thirds women, mostly middle-aged, mostly with back pain, fibromyalgia, and arthritis.
This is my canonical list of mind-over-pain treatments:
- Mainstream psychotherapeutic approaches, primarily CBT and ACT.
- Problem solving, goal setting, graded exposure and graded reactivation.
- Meditation/mindfulness, breathing exercises, relaxation.
- The major branded mind-body medicine approaches like Sarno’s “mind over back pain” and Schubiner’s Pain Reprocessing Therapy.
- Education, rational confidence building, pain neuroscience education (“explain pain”), SIMs/DIMs
- Neuro/psych “hacks”: virtual reality, mirror therapy, hypnotherapy, biofeedback, EMDR, placebo, open-label placebo.
- Distraction, pursuit of pleasure and happiness, catharsis/expression, art therapy (music, writing, dance, painting, etc).
- Therapies that involve some physicality or sensory input, but seem to be more about their emotional/psychological benefits, e.g. gentle massage, touch therapy.
- Why did they exclude them? Because they all came from the same source… and that source did not respond adequately to requests for clarification about their methods. So that’s four “positive” papers kicking around out there that were shunned by these reviewers. How many times do you think those papers have been cited to support CBT for chronic pain?
- Mascarenhas RO, Souza MB, Oliveira MX, et al. Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2020 Oct. PubMed #33104162 ❐ Referring to CBT, antidepressants, and CNS depressants, the researchers concluded: “Some therapies may reduce pain and improve QOL in the short to medium term, although the effect size of the associations might not be clinically important to patients.” In fact, the associations between these treatments and good outcomes were “were small and did not exceed the minimum clinically important change (2 points on an 11-point scale for pain and 14 points on a 101-point scale for quality of life).”
- It is common for those who promote dubious therapies and treatments to claim scientific support based on studies that were technically positive — but when you look at the data you only find evidence of a trivial beneficial effect. The evidence may be slightly positive, but it fails to impress. The treatment is damned with faint praise. See The “Impress Me” Test: Most controversial and alterantive therapies are fighting over scraps of “positive” scientific evidence that damn them with faint praise.
- When the data is adequate but only weakly positive, we can declare it to be effectively negative because of the lack of strongly positive results. What about when the evidence is inadequate? If there is a true absence of evidence — very few studies, or none at all, regardless of quality — then we cannot say much. But if there are more than a few papers, and the problem is just that they are too low quality, then it’s fair to declare a non-positive “result,” because genuine treatment effects probably won’t be missed by a bunch of low quality experiments that tend to err on the side of false positives. In other words, if a bunch of crappy papers cannot even produce a dubious positive, then it’s extremely unlikely that a bunch of highly quality ones will produce a real positive result.
- I think it’s obviously a major problem, because the great majority of trials are clearly just junk. The scientific publishing industry is in pretty rough shape these days. See 13 Kinds of Bogus Citations, Statistical Significance Abuse, and Ioannidis: Making Medical Science Look Bad Since 2005.
- The specific cause of chronic pain may often be less important than general sensitivity and biological vulnerability to any pain. The biggest risk factors for pain chronicity are things like poor health, fitness, and socioeconomic status, inequality… and they overshadow common scapegoats like poor posture, spinal degeneration, or even repetitive strain injury. How can nothing in particular make us hurt? Because pain is weird, a generally oversensitive alarm system that can produce false alarms even at the best of times, and more of them when your system is under strain. See Vulnerability to Chronic Pain: Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems.
- Saragiotto BT, Maher CG, Moseley AM, et al. A systematic review reveals that the credibility of subgroup claims in low back pain trials was low. J Clin Epidemiol. 2016 Jun. PubMed #27297201 ❐
- Saragiotto BT, Maher CG, Hancock MJ, Koes BW. Subgrouping Patients With Nonspecific Low Back Pain: Hope or Hype? J Orthop Sports Phys Ther. 2017 Feb;47(2):44–48. PubMed #28142361 ❐