We know that physical activity, self-management and healthy lifestyle habits can play an important role in managing arthritis. But managing chronic pain isn’t just about what is happening in the joints, pain can also affect our thoughts, emotions, behaviour, sleep and ability to participate in everyday activities.
There is evidence that psychological therapies such as cognitive behavioural therapy (CBT) can be helpful as part of a broader approach to chronic pain management. CBT doesn’t suggest that pain is “all in your head”, nor does it cure arthritis. Instead, it can help people understand the relationship between pain, thoughts, emotions and behaviours, and develop practical strategies for managing pain and living well with a chronic condition.
In this article, we explore what CBT is, how it may help people living with arthritis, and what you can expect from CBT for chronic pain.
What is CBT?
Cognitive behavioural therapy (CBT) is a psychological therapy that focuses on the relationship between our thoughts, feelings, behaviours and physical experiences. While CBT is commonly used to help manage anxiety and depression, it can also be used as part of chronic pain management.
So, why is this relevant to arthritis?
Living with arthritis and persistent pain can affect much more than your joints. Pain can influence your mood, sleep, confidence, activity levels and ability to participate in the things you enjoy. You may worry about the future, feel frustrated by limitations, or become concerned that movement or activity could make your pain worse.
CBT can help people recognise patterns of thinking and behaviour that may contribute to distress, fear, avoidance or difficulty managing pain. It can then provide practical strategies to develop more balanced ways of responding to pain and support participation in everyday activities.
Importantly, CBT does not mean that pain is “all in your head”. Pain is real and can involve complex interactions between biological, psychological and social factors. CBT is one approach that can complement other aspects of arthritis and pain management.
CBT may involve:
- Exploring how thoughts, emotions, behaviours and physical sensations interact.
- Identifying thoughts or behaviours that may be making it harder to manage pain or participate in everyday life.
- Developing more balanced and realistic ways of thinking about pain and its impact.
- Building practical skills to manage distress, increase confidence and work towards meaningful goals.
How can CBT help?
Handling emotional difficulties
Living with arthritis and persistent pain can contribute to feelings of anxiety, low mood, frustration and distress. CBT can provide practical tools to help people understand and manage these emotional responses.
Through strategies such as cognitive restructuring, people can learn to recognise unhelpful patterns of thinking and consider whether there may be alternative, more balanced ways of looking at a situation. This doesn’t mean replacing difficult thoughts with unrealistic positive thinking. Instead, the focus is on developing realistic and helpful ways of responding to challenges.
The aim isn’t to dismiss the person’s concerns, but to explore whether their current thoughts or beliefs are helping them move towards what matters to them and identify practical options.
Behavioural Adaptation
Pain can sometimes lead people to reduce their activity, avoid certain movements or stop doing activities they enjoy because they are worried about making their pain worse.
CBT can help people set realistic goals and gradually work towards activities that are important to them. This may involve pacing, planning activities, addressing fear or avoidance, and finding a sustainable balance between activity and rest.
The goal isn’t to simply “push through” pain. Instead, it is about building confidence, improving function and finding ways to participate in meaningful activities while managing symptoms.
For someone who has stopped exercising because they are worried movement will cause further damage, CBT may help them explore those concerns and develop a gradual, achievable approach to becoming active again, alongside appropriate advice from their healthcare team.
Pain, the Brain and the Body
Pain is a complex experience involving the nervous system, the brain and the body. While changes in the joints or other tissues can contribute to pain, the intensity of pain isn’t always directly proportional to the amount of physical change present.
With persistent pain, the nervous system can sometimes become more sensitive, meaning that pain signals may be amplified. Stress, poor sleep, anxiety, fear of movement and previous experiences with pain can also influence how pain is experienced.
This does not mean that pain is “all in your head”. The pain is real.
Instead, it highlights why chronic pain is best understood from a whole-person perspective. Biological factors, psychological factors and social circumstances can all influence how someone experiences and manages persistent pain.
CBT can help people understand some of these influences and develop practical strategies for responding to pain. This might include addressing unhelpful thoughts, reducing fear and avoidance, improving coping skills, managing stress and gradually returning to activities that are meaningful to them.
For example, someone might think:
“If I exercise, I’ll make my arthritis worse.”
CBT can help them explore this belief and consider whether there may be another way of approaching movement. With appropriate advice from their healthcare team, they may be able to identify safe and achievable forms of activity and gradually build their confidence.
CBT is not about ignoring physical symptoms or suggesting that psychological strategies can replace medical treatment. Instead, it can be one part of a broader approach to managing chronic pain alongside appropriate medical care, exercise, education and other treatments.
What can you expect from CBT?
CBT for chronic pain is usually structured and collaborative, with the therapist and individual working together to identify goals and develop practical strategies. The number and frequency of sessions can vary depending on the individual, their needs and the program.
When beginning CBT, you may experience:
1. An initial assessment
Your therapist may ask questions about your pain, health, mood, sleep, daily activities and how pain affects your life. This helps build an understanding of your individual experience and what you would like to work towards.
2. Understanding pain
You may learn more about the complex interaction between physical, psychological and social factors that can influence persistent pain.
3. Collaborative goal setting
You and your therapist can identify realistic goals based on the activities and aspects of life that are important to you.
4. Cognitive strategies
You may learn to recognise and explore unhelpful patterns of thinking related to pain and its impact and develop more balanced ways of responding.
5. Behavioural strategies
This may include gradually returning to activities, pacing, activity planning and addressing avoidance or fear of movement.
6. Pain coping skills
Depending on the program, this may include relaxation, mindfulness, breathing techniques, problem-solving or other strategies to help manage distress and improve your sense of control.
7. Problem-solving and adaptive thinking
You may develop strategies for responding to setbacks, managing challenges and adapting your approach when circumstances change.
8. Maintenance planning
Towards the end of therapy, you may develop a plan for continuing to use the skills you’ve learned and managing future challenges.
CBT is generally delivered over a series of sessions, although the length and format can vary. It may be provided face-to-face or, in some cases, remotely or online. Research suggests that psychological therapies, including CBT, can provide benefits for some people with chronic pain, although the size and duration of these benefits vary between individuals and studies.
CBT as part of a broader approach
CBT is not a replacement for medical or physical treatments for arthritis. Instead, it can complement approaches such as exercise, physical therapy, medication, education and self-management. Research suggests CBT can provide improvements in areas such as pain, disability and emotional distress for some people living with chronic pain. However, CBT is not a cure for arthritis, and it won’t be the right approach for everyone.
For some people, addressing the emotional and behavioural impact of persistent pain can make it easier to stay active, manage symptoms and continue participating in the activities, relationships and experiences that matter to them. Ultimately, managing chronic pain is about more than reducing pain alone. It’s about supporting your overall wellbeing, maintaining function and finding ways to live a meaningful life alongside your condition.
References:
Ismail, A., Moore, C., Alshishani, N., Yaseen, K., & Alshehri, M. A. (2017). Cognitive behavioural therapy and pain coping skills training for osteoarthritis knee pain management: a systematic review. Journal of physical therapy science, 29(12), 2228–2235. https://doi.org/10.1589/jpts.29.2228
Sharpe L. Psychosocial management of chronic pain in patients with rheumatoid arthritis: challenges and solutions. J Pain Res. 2016;9:137-146
https://doi.org/10.2147/JPR.S83653
