The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT and are used in the treatment of a variety of mental health disorders. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours, and how alterations in one domain can impact other domains. CBT therefore identifies, challenges, and modifies unhelpful cognitive structures, facilitating emotional and behavioural changes.
In the context of chronic pain management, CBT aims to facilitate acceptance of the pain, enhance patient’s coping mechanisms, and evaluate beliefs about pain with an aim to reduce the disability and distress associated with pain and improve quality of life. The goal is to improve quality of life, reduce pain-related impairments, and reduce pain intensity. At its core, CBT components for chronic pain management can include;
- Relaxation training: Focuses on returning the body to a relaxed state. Helps to manage stress and reduce muscle tension that can increase pain
- Exercise and pacing: Addresses avoidance response to chronic pain, and the cycle of negative consequences associated with inactivity (e.g. weight gain, sadness). Involves a thoughtful and sensible approach to increasing flexibility, strength, and better engagement with people and places
- Cognitive restructuring: Challenges the range of cognitive processes that result in unhelpful interpretations of the perception and severity of the pain event. It supports the development of a more balanced, adaptive thought process
- Behavioural activation: Increases engagement in behaviours that have positive influences on emotional state. Helps to change patients’ behaviours for the purpose of reinforcing positive context contingencies, and ending negative behaviours associated with emotional distress
CBT for chronic pain management also includes homework components which provide opportunities for patients to practice building and implementing their skills independently in real life settings outside of therapy.
Fidelity
Practitioners delivering CBT should receive training and ongoing clinical supervision. Practitioner competence and fidelity to treatment can be monitored and evaluated using appropriate measures, e.g., via recording of treatment sessions and use of fidelity checklists to determine practitioner adherence against a CBT competency assessment tool, such as the Cognitive Therapy Scale-Revised (1), or another similar scale.
Modifiable Components
CBT for chronic pain management can be delivered over 8-12 sessions in individual or group formats. It can also be delivered as a guided self-help intervention (supported by workbooks, books, online, or via smartphone applications e.g. habit changer). CBT for chronic pain management can be delivered to children, young people and adults. Delivery to children and young people can also include parent components. CBT can be delivered in several settings including outpatient settings, hospitals, residential treatment settings, and community settings.
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
Support for Organisation / Practice
Implementation Support
Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychology Adult mental Health and CAMHS workstreams, including training relating to application in physical health settings from the physical health and paediatric teams.
Start-up Costs
There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations.
Building Staff Competency
Qualifications Required
Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).
Training Requirements
Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in applying CBT in physical health settings is available through the NES Psychology workstreams and also available through professional organisations such as the British Association of Behavioural and Cognitive Psychotherapies (BABCP).
Supervision Requirements
Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:
- NES Generic supervision competences training (GSC) (or equivalent)
- NES Specialist Supervision Training: CBT (adult or child focus)
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available that specifically supports CBT supervision skills.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
The biopsychosocial model is believed to be the most relevant heuristic for explaining chronic pain. The model recognises the influence of physical (pain), psychological (cognition and affect), behavioural, and social factors on the establishment and maintenance of pain. CBT for chronic pain management therefore addresses the factors identified in multidimensional biopsychosocial model for chronic pain. It focuses on behaviours, cognitions, and emotions, and their influence on pain perception and severity. Hence it targets the cognitive processes on which assumptions and beliefs about the pain are founded, and addresses behaviours that need to be discontinued or reinforced in order to increase coping capacity as it relates to pain. This is expected to translate to the achievement of functional recovery and its associated outcomes of increased activity, mood stability, and reduced need for use of pain medication.
Children and Young People (CYP) Evidence
Some of the best available evidence for CBT in CYP chronic pain management come from meta-analytic studies. These are described below starting with the most recent review.
The first meta-analytic study evaluated the effectiveness of internet-delivered CBT on chronic pain (2). The meta-analysis included 4 RCTs with 404 young people aged 11-17 years. Participants in the review presented with different kinds of chronic pain, including chronic headache.
The second meta-analytic study (3) evaluated the effectiveness of CBT on chronic pain. The analysis included 9 RCTs and participants had a range of pain conditions including headache, abdominal pain and Fibromyalgia.
A third evaluated computerised cognitive behaviour therapy for the treatment of pain (4). The meta-analysis included 4 studies. Participants were aged up to the age of 18 years and had experienced recurrent or continuous pain. CBT was delivered in web or computerized format.
A fourth meta-analytic study was conducted to evaluate the effectiveness of psychological therapies for management of chronic pain (5). The study included 25 RCTs with 1247 young people aged 9-17 years. Of these, 12 studies evaluated CBT interventions. Interventions were delivered face to face (in individual and group formats) and via computer applications. Participants in the review presented with different types of pain including headache, abdominal pain, and fibromyalgia. Separate meta-analytic results were provided for CBT.
CYP Outcomes
Compared to waitlist control, computerised educational programme, or other control therapy group, the following outcomes were observed;
- Significantly lower pain intensity at post-treatment (3-5)
- Significantly reduced functional impairment (3)
- Significantly reduced maladaptive parent behaviours/ parental protective behaviours at post-treatment (2)
Adult Evidence
Some of the best available evidence for CBT in adult chronic pain management come from meta-analytic studies. These are described below with the most recent publication first.
First is a Cochrane review that evaluated the effectiveness of psychological therapies for the management of chronic pain (excluding headache) (6). The review included 75 studies, with a total of 9401 participants. Participants were adults (aged 18 years or over) who reported pain of at least three months’ duration in any body site, not associated with a malignant disease. Majority of participants presented with fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. The largest evidence base in this review was for CBT (59 studies), and meta-analytic results for CBT were reported separately. Interventions were delivered in face-to-face format.
The second meta-analytic study was conducted to determine the effectiveness of psychological interventions on pain catastrophising in chronic non-cancer pain (7). The study included 79 studies (n = 9,914) in total. Of these, 28 studies evaluated CBT. Participant were adults aged 27 to 82 years. Spinal pain was reported as the most common pain condition. Interventions were delivered in face-to-face, (in individual and group), or as self-help formats, with varying levels of therapist assistance. Meta-analytic results for CBT compared to other interventions were reported separately.
The third meta-analytic study evaluated the effectiveness of internet interventions for the management of chronic pain (8). The study included 22 studies, of which 2 were conducted in children/ youths, and 19 were CBT-based interventions. Participants presented with fibromyalgia/widespread pain, back pain, chronic headache /or migraine, and mixed chronic pain conditions.
The fourth meta-analytic study was a Cochrane review that evaluated the effectiveness of internet-delivered psychological therapies in chronic pain management (9). The review included 15 studies (n=2435), of these, 14 studies evaluated psychological therapies of a CBT orientation. Participants were adults, aged 37-66 years.
Adult Outcomes
Compared to treatment as usual or wait-list control, the following outcomes were observed;
- Significantly reduced pain catastrophising at post-treatment (7,8), sustained at 6-12 months follow-up (7)
- Significantly reduced pain and disability at post-treatment (6,8,9) at follow-up (defined as 3 to 12 months post-treatment) (9). Effect on pain and disability maintained at six to 12 months follow up (6)
- Significantly reduced depression (8,9) and anxiety at post-treatment (9)
- Significantly reduced distress at post-treatment, and at six to 12 months follow up (6)
Need
Comparable Population
CBT has been shown to be effective for chronic pain management in children, young people, and adults. Effectiveness of CBT has been demonstrated across different types of pain including fibromyalgia, back pain, chronic headache and/or migraine, rheumatoid arthritis, and mixed chronic pain.
Desired Outcome
CBT for chronic pain management is associated with significant improvements across several outcomes including pain catastrophising, pain intensity, disability, depression, anxiety, and distress at post-treatment. Some of the outcomes have been sustained at 6-12 months follow-up
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
In the context of chronic pain management, CBT aims to facilitate acceptance of the pain, enhance patient’s coping mechanisms, and remove patient’s equation of pain with disability. Models that have emerged to understand the development, maintenance, and management of chronic pain include the biopsychosocial model for chronic pain and cognitive behavioural model of chronic pain.
Priorities
CBT chronic pain management aims to improve quality of life, reduce pain-related impairments, and reduce pain intensity. To achieve this, CBT targets the cognitive processes on which assumptions and beliefs about the pain are founded, and addresses behaviours that need to be discontinued or reinforced in order to increase coping capacity as it relates to pain. CBT can be delivered to children, young people and adults; in individual, group or family formats; either in-person or as a remotely delivered intervention.
Existing Initiavtives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Cognitive Behavioural Therapy can be delivered by healthcare professionals (e.g. psychologists, mental health nurses) who have undergone training to support its delivery. CBT can be delivered to patients weekly, typically over 8-12 sessions. CBT can be delivered face to face or remotely.
Technology Support
Cognitive Behavioural Therapy can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.
Administrative Support
CBT for chronic pain management can be delivered face to face (individual or group) or as a remotely delivered intervention. In-person delivery can be held in several settings including outpatient settings, hospitals, and residential treatment settings. CBT for chronic pain management in children and adolescents can also include parent sessions. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
