Cognitive behavioral therapy (CBT) is a psychosocial intervention approach in which behavioral change is initiated by a therapist helping patients to confront and modify the irrational thoughts and beliefs that are most likely at the root of their maladaptive behaviors. Maladaptive behaviors are those that prevent an individual from adjusting appropriately to normal situations, and which are considered counterproductive or not socially acceptable (Figure 21-1).1 The primary goal of CBT is to identify these maladaptive behaviors, recognize beliefs associated with those behaviors, correct any inappropriate beliefs, and replace those beliefs with more appropriate ones that will result in greater coping skills and adaptive behaviors (Figure 21-2).
There are several approaches to CBT and various ways of incorporating CBT into the management of chronic low back pain (CLBP). CBT alone does not address all of the contributing factors to CLBP (e.g., anatomic, biologic, physiologic), and it is not intended to replace interventions aimed at correcting those factors when appropriate. The focus of CBT in the context of CLBP is mainly to address psychological comorbidities that may impede recovery. If those factors are solely responsible for CLBP, then CBT may be appropriate as the main intervention. However, patients sometimes find it difficult to perceive the utility of CBT as the sole treatment for CLBP.2 Use of the term CBT varies widely and may be used to denote self-instructions (e.g., distraction, imagery, motivational self-talk), relaxation, biofeedback, development of adaptive coping strategies (e.g., minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting (Figure 21-3).3Patients referred for CBT may be exposed to varying selections of these strategies that are specifically tailored to their needs.