CBT for chronic pain, chronic low back pain, chronic headache, IBS and tinnitus

1. Introduction

Version followed: the VA Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) therapist manual (Murphy, McKellar, Raffa, Clark, Kerns & Karlin; 12 sessions) as the core protocol, with Brief CBT-CP v2.0 (Beehler, Murphy, King & Dollar, 2021) and its patient guidebook for skill content. Condition modules: graded exposure in vivo and operant graded activity for chronic low back pain (Vlaeyen et al., 2002; Fordyce lineage); migraine-specific integrative CBT (Klan et al., 2022) plus Martin's Learning to Cope with Triggers for headache; Lackner's standard and minimal-contact CBT for IBS (IBSOS protocol); Andersson-derived guided internet CBT for tinnitus (Beukes et al., UK protocol). NICE NG193 and NG155 set where these sit in care.

This is a family of protocols, not one therapy. They share one learning model and one toolkit, then add condition-specific modules. Two roots: Fordyce's operant approach (1970s), which treats pain behaviour as shaped by its consequences and rebuilds activity on time rather than pain, and the cognitive-behavioural approach of Turk, Meichenbaum and Genest (1983), which targets the beliefs, appraisals and coping that drive distress and disability [source: Wegener, Wolfman & Haythornthwaite 2011; Vlaeyen et al. 2002].

Core idea of change: chronic pain (and persistent bowel symptoms or tinnitus) is real and physiologically maintained, but its impact is amplified by a cycle of fear, catastrophic thinking, avoidance or overdoing, deconditioning, poor sleep, low mood and withdrawal. The aim is not cure. It is less interference and distress and more function, through skills the patient practises until they feel able to control their response. Symptom reduction may follow [source: VA CBT-CP manual Part 1; VA Brief CBT-CP Module 1]. In fear-avoidant patients, change comes from testing feared predictions ("this movement will damage my back") by direct exposure [source: Vlaeyen et al. 2002].

2. Framework

Generic phase model (Turk lineage). Reconceptualisation (shared biopsychosocial model) → skills acquisition → skills consolidation and rehearsal → application, generalisation and relapse prevention. Skills are learned first in low-pain periods, then applied to harder episodes [source: Wegener et al. 2011 for the low-pain-first rule; phase names from Turk, Meichenbaum & Genest 1983, [uncertain]].

Core protocol: VA CBT-CP (individual, about 50 to 60 min, weekly) [source: VA CBT-CP manual; VA Brief CBT-CP]

Phase	Sessions	Goals
Assessment and engagement	1 Interview and assessment; 2 Treatment orientation (chronic pain cycle); 3 Assessment feedback and goal setting	Rapport, validation, measures, contact with primary care, shared model, SMART goals
Skills	4 Exercise and pacing; 5 Relaxation; 6–7 Pleasant activities; 8–9 Cognitive coping; 10 Sleep	Activation, arousal reduction, re-engagement, cognitive coping, sleep
Consolidation	11 Discharge planning; 12 Booster about one month later	Keep gains, anticipate obstacles, follow-up

The manual's Part 1 places relaxation in sessions 5 and 6, but its contents list puts pleasant activities at 6. Follow the contents list and extend relaxation if needed [uncertain].

Brief CBT-CP (primary care). Six modules of about 30 min over 6 to 12 weeks: 1 Education and goals (always first); 2 Activities and pacing; 3 Relaxation; 4–5 Cognitive coping 1 and 2; 6 Pain Action Plan (always last). Modules 2 to 5 may be reordered by patient preference or clinical judgement [source: VA Brief CBT-CP].

Standard session structure [source: VA CBT-CP manual; VA Brief CBT-CP]: (1) brief mood check (distress rating in the full protocol; PEG three-item pain, enjoyment and activity scale in Brief); (2) set agenda together, invite additions; (3) bridge from last session and review home practice; (4) new skill with rationale, demonstration, and the patient's reaction; (5) agree manageable home practice; (6) summary. Brief CBT-CP time budget: agenda 1–2 min, mood and PEG 3–4, review 3–5, new material 12–15, home practice 2–3, wrap-up 1–2.

Condition-specific formats

Chronic low back pain with high fear of movement: graded exposure in vivo in 3-week blocks, then a week of independent home practice with no therapist contact. Operant graded activity is the alternative for low-fear, deconditioned patients [source: Vlaeyen et al. 2002].
Headache/migraine: miCBT is 7 weekly 90-minute groups of 4 to 9: education; lifestyle; fear of attacks; coping during an attack; trigger management; stress management; closing and long-term goals. Each session after the first ends with a short relaxation exercise [source: Klan et al. 2022].
IBS: standard CBT is 10 weekly one-hour individual sessions. Minimal-contact CBT is 4 one-hour clinic visits over 10 weeks plus self-study materials and two 10-minute phone calls (weeks 3 and 7) [source: IBSOS protocol].
Tinnitus: an 8-week guided internet programme with weekly modules, worksheets and secure-message support. NICE steps care: tinnitus support first; then digital tinnitus CBT; then group MBCT, ACT or CBT; then individual tinnitus CBT, moving up a step if the person declines or does not benefit [source: Beukes et al. protocol NCT02370810; NICE NG155 1.5.4].
Chronic primary pain generally: NICE NG193 recommends considering CBT or ACT for people aged 16 and over [uncertain: stated from the published guideline].

Criteria for moving on and ending [source: VA Brief CBT-CP troubleshooting section; rest [synthesis]]

Move from assessment to skills once there is a shared model the patient can state in their own words and at least one SMART goal [synthesis].
Move to the next skill once the current one is being practised at home, even imperfectly. Mastery is not required, because later sessions revisit earlier skills [synthesis].
Track the PEG (or the condition measure: Tinnitus Functional Index, a headache diary, an IBS symptom score) every session. A 30% fall is clinically meaningful [source: VA Brief CBT-CP].
Improved: confirm with the patient, review goals, plan ending with an open door. No change: explore barriers (missed practice, changed goals), revisit or add modules. If skills were used and there is still no change, refer to specialist pain or behavioural medicine. Worse: assess suicide risk and safety first, then decide whether the cause is transient (an overexertion flare) or stable (reinjury, new diagnosis, life stressor), and consider stepping up care [source: VA Brief CBT-CP].
In exposure, move up the hierarchy only when the patient's harm expectancy for the current item has clearly dropped [source: Vlaeyen et al. 2002].

3. Guiding principles

[source: VA CBT-CP manual Part 1 and therapist considerations; VA Brief CBT-CP; Vlaeyen et al. 2002; Wegener et al. 2011; NICE NG155; items marked [synthesis] are mine]

The pain is real. Never debate whether symptoms are "real" or "psychological". State plainly that you take them as described.
Biopsychosocial, not psychological-only. Present body, thoughts, emotions, behaviour and social context as interacting, so the referral does not feel like being told "it's in your head".
Coping and quality of life, not cure. Name the goal early: less interference and better function. Pain reduction is possible but is not promised.
Compassionate yet directive. Offer warmth and safety, and also give clear structure, rationale and assignments.
Collaborative. Set agendas together, choose goals together, negotiate homework and exposure items. Nothing is imposed.
Motivational-interviewing stance for ambivalence. Use open questions, affirmations, reflections and summaries. Notice and reinforce change talk, such as statements of more control.
Alliance is foundational. Monitor it. The VA protocol uses the short Working Alliance Inventory.
Measurement-based care. Brief standard measures every session guide decisions, not just audit them.
Home practice is the treatment. Skills practised between sessions predict outcome. Keep tasks small enough to be done.
"Hurt does not equal harm" (VA Brief CBT-CP). In chronic pain, protective withdrawal no longer serves healing. Activity is safe unless medically contraindicated.
Time-contingent, not pain-contingent. Activity and rest are set by the clock or a quota, not by how the pain feels in the moment.
Balanced, not positive, thinking. Aim for accurate thoughts that acknowledge pain and still point to action.
Learn in calm, apply in difficulty. Practise skills at low pain or arousal first, then generalise.
Reinforce well behaviour, give pain behaviour less attention (operant lineage). Applies to the therapist and to family.
Medical decisions stay medical. Acknowledge frustration about medication or procedures, refer to the prescriber, and work as one team with primary care.
Red flags go to medical review. New radiating pain, new weakness, sudden hearing loss and new neurological signs get urgent referral, not coping skills (VA CBT-CP; NICE NG155 1.2).
No "correct posture" rules during exposure. Ergonomic instructions imply that harm follows if done "wrong", which feeds fear (Vlaeyen et al. 2002).
Acceptance is active. Accepting chronicity means stopping a fruitless fight for a cure in order to live well. It is not giving up. Normalise grief for lost roles.
Information-giving is two-way (tinnitus support, NICE NG155). Discuss the person's own concerns, give tailored information, agree a plan they prefer.
Fit the module to the formulation [synthesis]. Use exposure for fear-avoidance, pacing for boom-bust patterns, and trigger work for headache. Not every patient needs every module.

4. Intervention inventory

The inventory runs in order: assessment and engagement (A), education and goals (B), activity-based (C), arousal reduction (D), cognitive (E), condition-specific (F), maintenance (G). All example language is my illustrative wording unless quoted and cited.

A1. Clinical interview and assessment

Purpose / when: Session 1 of every course. Builds the formulation, the baseline and the alliance [source: VA CBT-CP manual, Session 1].
Steps: (1) Pain map: primary and secondary sites, onset (single event or gradual), quality, intensity. (2) Treatments tried, current and past, and why each did not help. (3) Current medications (record them, do not advise). (4) What makes it worse and better; walk through a typical day hour by hour. (5) Impact on mood, sleep, mobility, work, hobbies, relationships. (6) Measures: VA uses 0–10 average, worst and least pain over the past week, the Pain Catastrophizing Scale, the interference subscale of the West Haven-Yale Multidimensional Pain Inventory, plus mood and sleep measures. Brief CBT-CP uses the PEG every session. For tinnitus, NICE suggests the Tinnitus Functional Index, the (mini-)Tinnitus Questionnaire if needed, the Insomnia Severity Index and a mood measure such as CORE-OM. (7) Screen for red flags and suicide risk. (8) With consent, contact the primary care clinician to coordinate. Give measures at baseline, mid-point and discharge; ask patients to arrive 15–20 min early [source: VA CBT-CP manual; VA Brief CBT-CP; NICE NG155 1.3].
Example language (illustrative): "I'm not here to decide whether your pain is real. I take it that it is. I want to understand what it has taken from your life, so we can work on getting some of that back."
Watch for: Reluctance to complete questionnaires. Explain them like vital signs, which the VA manual suggests, and problem-solve barriers. Also watch for anger at past providers and new or changing neurological symptoms (refer). For tinnitus, find out why a person with long-standing symptoms is seeking help now (NICE NG155 1.1.2).

A2. Self-monitoring (diaries and logs)

Purpose / when: From session 1 onwards. Makes links between activity, stress, thoughts and symptoms visible, and supplies data for every later skill [source: IBSOS protocol; Beukes et al. protocol; VA Brief CBT-CP guidebook].
Steps: (1) Pick one simple log per condition: activity–rest log (pain); headache diary with attacks, triggers, medication days and what was tried (headache); a record of stressful situations alongside IBS episodes (IBS); a weekly practice worksheet of when, where and how long each technique was used and how well it worked (tinnitus). (2) Agree when to fill it in, such as once each evening. (3) Review it at the start of each session and pull out one pattern together. (4) Drop columns that are not being used.
Example language (illustrative): "Let's look for what tends to come before the bad days. You keep the record and we'll work out the patterns together."
Watch for: Hourly symptom rating can feed hypervigilance. Keep symptom ratings to once or twice a day and log behaviour more than sensation [synthesis].

B1. Pain education and the chronic pain cycle (treatment orientation)

Purpose / when: Sessions 2–3 (full protocol) or Module 1 (Brief). Shifts the model from "damage needing protection" to "a condition to manage" [source: VA CBT-CP manual; VA Brief CBT-CP Module 1; guidebook].
Steps: (1) Acute versus chronic pain: rest and guarding help an injury heal, but the same responses keep chronic pain going. (2) Go through the biological, psychological and social factors that raise or lower pain, and ask which affect this patient most. (3) Draw the chronic pain cycle using their own examples: pain → fear and negative thoughts → inactivity and withdrawal → deconditioning and low mood → more pain and disability. (4) Show where each skill in the programme breaks the cycle. (5) Ask for their reaction and their version of the model.
Example language (illustrative): "When you sprain an ankle, resting it is exactly right. When pain has gone on for years, resting can quietly become part of what keeps it going."
Watch for: Signs the patient hears "psychological" as "imaginary", such as going quiet or saying "so you think I'm making it up". Restate that the pain is real and the nervous system is part of the body. It is working when the patient can explain the cycle in their own words and place themselves on it.
Condition versions: Headache: attack phases, a biopsychosocial model, and the idea of an attack threshold that load from many factors pushes over [source: Klan et al. 2022]. IBS: education about stress and IBS symptoms [source: IBSOS protocol]. Tinnitus: what tinnitus is, that it is common and may settle, what makes it worse, safe listening, sleep, self-help and support groups [source: NICE NG155 1.1; Beukes et al.].

B2. Individualised fear-avoidance model (for fear of movement)

Purpose / when: First exposure session for patients with high fear of movement or reinjury, typically chronic low back pain [source: Vlaeyen et al. 2002].
Steps: (1) Present pain as common and self-manageable, not a sign of serious disease that needs protecting. (2) Build the fear-avoidance cycle from the patient's own material: a pain episode → catastrophic interpretation ("something is damaged") → fear → avoidance and hypervigilance → disuse, disability, low mood → more pain. (3) Contrast this with the recovery path: pain → low fear → confrontation → recovery. (4) Introduce exposure as a way to test the beliefs directly.
Example language (illustrative): "Your back pain hasn't been the only problem. Your mind has learned that bending means damage, and so you stopped bending. We can test that belief carefully."
Watch for: Agreement that is only intellectual. The real test is whether they are willing to try the first hierarchy item.

B3. SMART goal setting

Purpose / when: Session 3 or Module 1, revisited at discharge. Turns "less pain" into functional, measurable targets [source: VA Brief CBT-CP Module 1; guidebook].
Steps: (1) Ask what they would be doing day to day if treatment worked. (2) Shape it into a goal that is Specific, Measurable, Attainable, Relevant and Time-bound. (3) Set at least one short-term goal in session; finish any others as homework. (4) At discharge, set new goals for about 3 months and for 6–12 months.
Example language: The VA manual asks what the patient would like to see change in the coming weeks, and how success would look day to day. Illustrative: "Instead of 'get my life back', what's one thing you'd be doing by the end of next month?"
Watch for: Goals that are about pain intensity only ("pain at 3"). Reframe them toward activity. Overambitious goals set up a boom-bust cycle.

C1. Activity pacing (time-based)

Purpose / when: Session 4 or Module 2. For boom-bust patterns (overdoing on good days, then crashing) and for underactivity [source: VA Brief CBT-CP guidebook; VA CBT-CP manual].
Steps: (1) Choose two activities that matter, such as housework or sitting at a computer. (2) Estimate how long the patient can do each without a severe flare. (3) Set active time slightly below that estimate (the guidebook uses one minute under). (4) Set a rest or change-of-position period long enough to recover. (5) Repeat active and rest cycles, keep to the plan on good and bad days, and spread tasks across the week. (6) Log the planned active and rest times and cycles per day. (7) Review and adjust. Increase gradually once the plan is reliable [synthesis for the increase rule; see C2]. A worked example uses a short scheduled break every 30 min and changing task or posture after it.
Example language (illustrative): "We're going to let the clock decide when you stop, not the pain. Stop while you're still OK, rest, then go again."
Watch for: Pushing through "just to finish" on good days, and turning pacing into a reason to avoid. It is working when there are fewer flares after activity and total activity across the week rises.

C2. Graded activity: operant, time- or quota-contingent (Fordyce lineage)

Purpose / when: For deconditioned patients with low fear and a pain-contingent pattern of stopping. Often run with physiotherapy [source: Wegener et al. 2011; Vlaeyen et al. 2002].
Steps: (1) Baseline: record how long or how much the patient does of each target activity when told to continue until pain stops them, over about a week. (2) Start below baseline: Wegener et al. describe starting at about 70–80% of baseline. (3) Raise the quota in small planned steps: they cite increases of no more than about 5% a week. (4) Stop when the quota is reached, not when pain rises, and stop at the quota even when feeling good. (5) Give clear praise and attention when quotas are met, and chart progress where it can be seen. (6) Teach family the same rules (see C3).
Example language (illustrative): "Today's target is 8 minutes on the bike. When you get there, you stop, whether it's a good day or a bad one."
Watch for: Quotas set by pain on the day, and skipped sessions after a bad night. It is working when quotas are met steadily and the graph rises.

C3. Contingency management of pain behaviour and involving family

Purpose / when: When others' responses (solicitous help, sympathy, taking over tasks) or the clinic's own responses reward pain behaviour and discourage activity [source: Wegener et al. 2011; VA CBT-CP manual therapist considerations].
Steps: (1) With the patient, identify pain behaviours (grimacing, guarding, resting in view of others, repeated complaints) and well behaviours (activity, attending therapy, social contact). (2) In session, give warm attention to reports of activity and coping; acknowledge pain reports briefly and return to the plan. (3) With consent, meet the partner or family and explain the cycle. Coach them to notice and praise effort, stop doing tasks the patient can do, and respond to pain displays with calm brief acknowledgement rather than rescue. (4) Watch for a partner whose caretaking role is threatened by the patient's progress.
Example language (illustrative): To a partner: "When you jump in and do it for them, it's out of love. We're asking you to try something harder: notice and cheer the doing."
Watch for: The patient feeling ignored or disbelieved. Always pair less attention to pain with explicit validation and more attention to coping [synthesis].

C4. Time-contingent medication schedule (prescriber-led)

Purpose / when: In operant programmes, as-needed analgesia is switched to fixed intervals, so taking medication is no longer the reward for complaining [source: Wegener et al. 2011].
Steps: The psychologist does not make medication changes. (1) Note pain-contingent use patterns in the log. (2) Raise them with the prescriber as part of shared care. (3) Support whatever schedule the prescriber sets with monitoring and coping skills. For headache, record medication days in the diary for the prescriber.
Watch for: Patients asking you about drugs. Acknowledge, refer, and redirect to skills [source: VA Brief CBT-CP].

C5. Pleasant activity scheduling

Purpose / when: Sessions 6–7 or Module 2. Reverses withdrawal and low mood and restores rewarding experience [source: VA CBT-CP manual; guidebook].
Steps: (1) From a list, tick activities that have helped before or that they would like to try, and add their own. (2) Schedule at least two specific ones for the coming week on a calendar. (3) Circle each one when done. (4) Pace them, and don't overdo them on good days. (5) Review which ones changed mood or pain and build on them.
Example language (illustrative): "Pain has been deciding what's in your week. Let's put two things back in that you'd choose for yourself."
Watch for: Choosing only passive or solitary activities, and "I'll do it when the pain's better". The activity comes first; the improvement follows.

C6. Graded exposure in vivo (pain-related fear)

Purpose / when: For high fear of movement or reinjury with avoidance, mostly chronic low back pain. Use after the fear-avoidance education (B2) [source: Vlaeyen et al. 2002].
Safety and consent (do first): Get medical clearance that there is no structural contraindication. Screen for red flags; new radiating pain or weakness needs immediate medical review (VA CBT-CP). Explain the rationale and that discomfort and temporary pain increases are expected. Agree every item in advance and confirm it is safe and reasonable; the patient may stop at any point. Use a fear-of-movement measure to select patients [synthesis on measure selection; the Tampa Scale for Kinesiophobia is commonly used, [uncertain]].
Steps: (1) Build a hierarchy. Vlaeyen et al. used the Photograph Series of Daily Activities (PHODA): the patient places photos of everyday movements on a 0–100 "fear thermometer" by how harmful each feels for their back. Without PHODA, use a written list of the patient's own avoided activities rated the same way [synthesis]. (2) Start with a low-rated item. (3) The therapist models the movement first. (4) Before the activity, the patient rates how likely they think harm is and states the specific prediction. (5) They do the activity and repeat it. (6) Re-rate the harm expectancy afterwards and compare it with what happened (a behavioural experiment). (7) Repeat until fear and expectancy fall clearly, then move up. (8) Leave out instructions about lifting technique or posture. (9) Generalise: practise at home and in the real setting; Vlaeyen et al. used a home-practice week with an activity monitor.
Example language (illustrative): "Before you bend for the box, how likely is it, out of 100, that this damages your back? … You've done it five times. What happened, compared with what you expected?"
Watch for: Subtle safety behaviours (bracing, half-movements, holding breath), which you should name and gradually drop. Watch for distraction during exposure and for pain increases being read as proof of harm. It is working when harm ratings fall between first and last trials and avoided activities reappear at home.

D1. Diaphragmatic (deep) breathing

Purpose / when: Session 5 or Module 3, and tinnitus relaxation step 2. Pain and symptoms set off a stress response that adds tension; relaxation is a trained skill and is not the same as resting [source: guidebook Module 3; Beukes et al.].
Steps: (1) Sit comfortably with one hand on the chest and one on the belly. (2) Notice the natural rate and depth of the breath without changing it. (3) Breathe slowly into the belly so the lower hand rises, pause briefly, and breathe out fully, counting in and out. (4) Notice cool air coming in and warm air going out. (5) Let the breath settle smooth and slow, with the shoulders dropping on each out-breath. (6) Return to alertness by counting down from five to one. Practise twice a day; the tinnitus programme uses 5–7 min twice daily. The Brief CBT-CP handout also has a counting variant: count breaths one to ten in sets, for at least 5 min, 2–3 times a day.
Example language (illustrative): "Let the hand on your belly do the moving. The one on your chest can stay fairly still."
Watch for: Over-breathing or light-headedness: slow down and make breaths smaller. Trying hard to relax, which defeats it. Log tension 0–10 before and after (see D2).

D2. Progressive muscle relaxation (PMR)

Purpose / when: Session 5 or Module 3. Teaches noticing and releasing muscle tension [source: guidebook Module 3; Wegener et al. 2011; Klan et al. used Bernstein & Borkovec-based PMR as the active comparison].
Steps: (1) Quiet setting, at the same time each day. (2) Tense each muscle group firmly but not painfully for about 5 s, then release for about 10 s and notice the difference. (3) Sequence: hands and arms, legs, abdomen, chest, neck and shoulders, jaw, eyes, forehead and scalp. (4) Scan for any tension left. (5) Deepen by counting one to five, linking a cue word such as "calm" to each out-breath. (6) Count back to alertness. (7) Log minutes practised and tension 0–10 before and after on the practice record. (8) Over time, move the skill into daily situations using the cue word.
Example language (illustrative): "Tense just enough to feel it, not enough to hurt. Then let go and notice what changes."
Watch for: Tensing painful areas. Skip them or use release-only (just let go without tensing) [synthesis]. Watch for cramps. It is working when the before and after ratings show a drop and the patient starts using the cue word without prompting.

D3. Guided and positive imagery

Purpose / when: As an extra relaxation tool, and in tinnitus week 4 after relaxation practice to deepen it [source: Wegener et al. 2011; Beukes et al.; the Brief CBT-CP imagery script is in an appendix, [uncertain]].
Steps: (1) After breathing or PMR, ask the patient to choose a calm, safe scene. (2) Guide attention through each sense in turn: sight, sound, touch, smell. (3) Let them stay in the scene a few minutes. (4) Bring them back gradually. (5) Record it for home use.
Example language (illustrative): "Notice the temperature of the air there… what you can hear in the distance…"
Watch for: Scenes that turn upsetting. Let the patient choose and change the scene. For tinnitus, avoid scenes that depend on silence [synthesis].

D4. Stepped relaxation down to rapid and applied use (tinnitus programme; usable for pain)

Purpose / when: Tinnitus iCBT weeks 2–7. Moves from long practice to brief relaxation used in real situations [source: Beukes et al. protocol].
Steps: Step 1: deep relaxation, 10–15 min twice daily. Step 2: diaphragmatic breathing, 5–7 min twice daily. Step 3: whole-body relaxation, 2–3 min twice daily. Step 4: rapid relaxation, 20–60 s, 5–10 times a day. Step 5: rapid relaxation in more difficult situations, 30–60 s, 10–15 times a day. Step 6: build it into routines, 10–20 times a day. Log when, where, how long and how effective each practice was. The protocol does not describe the content of each step in detail; Andersson's programme is derived from Öst's applied relaxation [uncertain: Öst lineage not confirmed].
Example language (illustrative): "This week, every time you look at your phone, take one slow breath and let your shoulders drop. That's the whole exercise."
Watch for: Skipping the long early steps. Rapid relaxation only works once the long version is learned.

D5. Biofeedback (headache)

Purpose / when: EMG (muscle tension) or skin-temperature feedback to teach voluntary control. Best supported for headache [source: Wegener et al. 2011]. NICE NG193 advises against biofeedback for chronic primary pain [uncertain], so offer it for headache within specialist services, not as a general pain intervention [synthesis].
Steps: Requires equipment and training, so refer to a trained provider. In general terms: sensors show tension or hand temperature on screen; the patient practises relaxation strategies while watching the signal change, then practises without feedback.
Watch for: Device dependence. Fade the feedback over time.

E1. Identifying automatic negative thoughts and unhelpful thinking styles

Purpose / when: Session 8 or Module 4. Thoughts do not cause the pain, but they shape how it is felt and coped with [source: guidebook Module 4; VA CBT-CP manual].
Steps: (1) Explain automatic negative thoughts (ANTs): fast, believable and feel out of your control. (2) Elicit a recent pain moment and the thought that came with it. (3) Go through the thinking styles (the guidebook's list): catastrophising, "should" statements, all-or-nothing thinking, overgeneralising, jumping to conclusions (for example, assuming harm), emotional reasoning, and disqualifying the positive. (4) Ask which ones the patient recognises. (5) Homework: catch at least one ANT a day, write down the day and situation, and rate it. Leave challenging for the next session.
Example language (illustrative): "What went through your mind right when the pain spiked on the stairs?"
Watch for: Patients hearing "your thinking is wrong". Frame the thoughts as understandable, but costly.

E2. Catch, Check, Challenge (cognitive restructuring)

Purpose / when: Sessions 8–9 or Modules 4–5. Tinnitus week 3 uses the same idea with a situation, thoughts and feelings record [source: guidebook; Beukes et al.; Wegener et al. 2011].
Steps: (1) Catch: write the thought down with the situation. (2) Check: was it helpful or unhelpful, and what did it do to pain, mood and behaviour? (3) Challenge: write a balanced alternative. A good one usually acknowledges the pain and gives a reason or a way to keep going. Useful questions: what is the evidence; what would I tell a friend; what can I still do [synthesis for the question list]. (4) Rate belief and mood after. (5) Continue daily, writing a balanced statement for each ANT.
Example language: The guidebook's model reply pairs a limit ("I can't do some things when it flares") with an action ("I can still do something if I pace"). Illustrative: "That's true and it's hard. What's the rest of the picture?"
Watch for: Forced positivity ("my pain is fine"), which patients reject. Aim for accurate. It is working when catastrophising scores and interference fall.

E3. Testing predictions (behavioural experiments)

Purpose / when: IBS minimal-contact CBT session 2 uses this to counter catastrophising. It is also the core of exposure (C6) [source: IBSOS protocol; Vlaeyen et al. 2002].
Steps: (1) State the feared prediction precisely: "If I go on the bus I'll have an accident." (2) Rate belief 0–100. (3) Plan a test that is safe and that the patient agrees to. (4) Carry it out without safety behaviours if possible. (5) Compare the outcome with the prediction and re-rate belief. (6) Write the new conclusion down.
Example language (illustrative): "Let's treat this as an experiment, not a test you can fail. Whatever happens, we learn something."
Watch for: Hidden safety behaviours that let the patient explain away the result ("it was fine because I took a tablet first").

E4. Coping statements

Purpose / when: Module 5. Ready-made balanced thoughts for flares and stress [source: guidebook Module 5].
Steps: (1) Go through a checklist of statements and tick the ones that fit. The checklist themes include: flares pass; I've got through this before; what would I tell a friend; focus on what I can do. (2) Add the patient's own, in their words. (3) Keep them somewhere at hand, such as a wallet card or phone note. (4) Rehearse them in session during a moment of imagined flare.
Example language (illustrative): "This is a flare, not a disaster. I know what to do: slow down, breathe, pace."
Watch for: Statements the patient doesn't believe. Rewrite them until they do.

E5. Modifying core beliefs (e.g., perfectionism)

Purpose / when: Later IBS CBT (phase 5; minimal-contact session 3), when a theme such as perfectionism, needing control, or putting others first keeps generating stress and symptom-focused thoughts [source: IBSOS protocol].
Steps: (1) Find the common theme across thought records. (2) Use the downward arrow ("if that were true, what would it mean about you?") to name the belief [synthesis: technique not detailed in the protocol]. (3) Look at the belief's costs and benefits. (4) Write a more flexible version. (5) Test it with behavioural experiments, such as deliberately doing a task to a "good enough" standard.
Example language (illustrative): "A lot of these thoughts seem to run on the same rule: 'I must never let anyone down.' Where did that rule come from?"
Watch for: Moving to belief work before the patient has basic restructuring skills.

E6. Problem-solving training

Purpose / when: IBS standard CBT phase 6 and minimal-contact session 3. For realistic stressors (work, toilet access, travel, relationships) where the problem is real rather than a thinking error [source: IBSOS protocol; Wegener et al. 2011]. Step detail is my synthesis of standard problem-solving therapy.
Steps: (1) Define the problem concretely. (2) Brainstorm options without judging them. (3) Weigh the pros and cons of each. (4) Choose one and plan it in detail. (5) Try it. (6) Review and adjust.
Example language (illustrative): "Let's list every option, even silly ones, before we judge any of them."
Watch for: Patients using problem-solving to plan more avoidance, such as only going to places with known toilets. Check that the solutions widen life rather than narrow it.

E7. Stress management via behavioural analysis

Purpose / when: miCBT session 6 (headache). Also IBS stress education and monitoring [source: Klan et al. 2022; IBSOS protocol].
Steps: (1) Pick a typical stressful situation. (2) Map it step by step: trigger → thoughts → feelings and body → behaviour → short- and long-term consequences, including headache or bowel symptoms. (3) Find a point to intervene: change the situation, the appraisal, or the response (relaxation, assertiveness, problem-solving). (4) Plan a specific coping strategy for the next occurrence. (5) Review it next session.
Example language (illustrative): "Walk me through Monday morning minute by minute, up to when the headache started."
Watch for: Analysis without a concrete plan at the end.

E8. Attention diversion and concentration

Purpose / when: A general coping skill (cognitive or behavioural distraction), and tinnitus's optional concentration tips (mentally engaging activities) [source: Wegener et al. 2011; Beukes et al.].
Steps: (1) List absorbing activities that fit the patient's abilities. (2) Plan them for high-symptom times. (3) Practise switching attention deliberately: name five things you can see, then hear, then feel [synthesis]. (4) Review what held attention.
Example language (illustrative): "Pain and tinnitus are loud when nothing else is. What fills your attention?"
Watch for: Distraction used to avoid feared activity, or during exposure. Keep it for coping with symptoms you can't change, not for escaping feared situations.

F1. Sleep module

Purpose / when: Session 10 of CBT-CP, which was informed by a CBT for insomnia manual. Optional sleep guidelines in tinnitus iCBT [source: VA CBT-CP manual; VA Brief CBT-CP; Beukes et al.; NICE NG155 1.3.5]. The step detail below is a synthesis from standard CBT-I; the session text is not drawn on [uncertain].
Steps: (1) Screen: Insomnia Severity Index; snoring or witnessed apnoeas (refer for a sleep study); refer for full CBT-I if insomnia criteria are met, deciding with the patient whether CBT-I or pain CBT comes first. (2) Sleep diary for 1–2 weeks. (3) Fixed wake time. (4) Bed only for sleep: get up after a prolonged wakeful spell and return when sleepy. (5) Wind-down routine using relaxation (D1–D3). (6) Limit daytime napping, caffeine and alcohol, and plan pain-related position changes. (7) For tinnitus, use low-level background sound at night (see F6).
Example language (illustrative): "We'll anchor the morning first. A steady get-up time is the backbone of better sleep."
Watch for: Long time in bed "resting" the pain, which fragments sleep.

F2. Headache: lifestyle counselling

Purpose / when: miCBT session 2. Builds headache-friendly regularity in relaxation, recreation and regular physical activity, with personal goals [source: Klan et al. 2022].
Steps: (1) Review the diary for irregular sleep, meals, activity and overload. (2) Choose one or two habits to make more regular. (3) Set SMART goals (B3). (4) Review them next session.
Example language (illustrative): "Your brain seems to like predictability. Which part of your routine is least predictable right now?"
Watch for: Rigid rule-making driven by fear of attacks. That shades into avoidance; see F4.

F3. Headache: coping with fear of attacks

Purpose / when: miCBT session 3. For anticipatory anxiety about the next attack, which narrows life and raises arousal [source: Klan et al. 2022].
Steps: (1) Map the anxiety vicious circle: a bodily cue or worry → fearful prediction → anxiety and arousal → more vigilance and avoidance → more attacks or more disability. (2) Identify the feared predictions ("I'll get one at the wedding and ruin it"). (3) Restructure them (E2) and test them (E3). (4) Reduce avoidance and safety behaviours in steps.
Example language (illustrative): "How much of your week goes into preventing an attack, compared with how often attacks actually happen?"
Watch for: Over-reliance on precautionary medication. Coordinate with the prescriber, because medication-overuse headache is a medical concern.

F4. Headache: coping with an ongoing attack

Purpose / when: miCBT session 4. Planning what to do during attacks [source: Klan et al. 2022].
Steps: (1) Review the last attack: when medication was taken (per the prescriber's plan), how much activity was kept up, what was said to others, and what thoughts came. (2) Write an attack plan: take medication early as prescribed; decide which activities are kept, reduced or dropped; a short script for telling others; relaxation; coping statements (E4). (3) Rehearse it.
Example language (illustrative): "Let's write what 'good handling' of an attack looks like for you, so you're not deciding it from scratch in the middle of the pain."
Watch for: All-or-nothing collapse of activity, and secrecy or guilt about attacks.

F5. Headache: trigger management, including Learning to Cope with Triggers (LCT)

Purpose / when: miCBT session 5. Martin proposes that blanket avoidance of triggers can sensitise people to them, so some triggers should be exposed to rather than avoided [source: Klan et al. 2022; Martin et al. 2021 abstract].
Steps: (1) From the diary, list suspected triggers and pick the five most relevant. (2) For each, choose one of five strategies (Klan et al.): experiment (test whether it really is a trigger, for example by systematically varying exposure and recording headaches); avoid (for triggers that are harmful or easy to avoid); cope with stress (apply E7 where stress is the trigger); exposure (graded, planned contact to reduce sensitivity, for triggers whose avoidance costs a lot, such as fatigue, light, noise or emotional stress); acceptance (for triggers that can't be changed, such as weather). (3) For exposure triggers: build a hierarchy, start brief and mild, combine with relaxation and coping thoughts, and extend gradually. (4) Record outcomes. Which triggers suit exposure, and the grading parameters, come from Martin's full trial report, which is not drawn on [uncertain].
Example language (illustrative): "Avoiding every bright room may have made your brain more sensitive to light. We could test building tolerance in small doses."
Watch for: Triggers that are dangerous to expose to, such as alcohol, or that are clear dietary triggers for that person. Avoid those [synthesis]. Get the patient's consent, warn that headaches may rise temporarily, and coordinate with the neurologist.

F6. Tinnitus: sound enrichment

Purpose / when: An optional tinnitus iCBT module. Uses background sound to reduce contrast and silence-driven focus. NICE makes no practice recommendation on sound therapy, and hearing aids are for associated hearing loss [source: Beukes et al.; NICE NG155 1.5].
Steps: (1) Identify quiet settings where tinnitus bothers the person most, such as the bedroom or office. (2) Add low-level, pleasant, non-masking background sound: nature sounds, fan, soft music. (3) Keep it below the tinnitus level, so it softens contrast rather than hiding the tinnitus [synthesis]. (4) Log the effect.
Example language (illustrative): "Silence makes the tinnitus stand out. A little background sound can take the edge off."
Watch for: Loud masking all day, which can become a safety behaviour. Check whether there is hearing loss and refer to audiology.

F7. Tinnitus: reinterpretation

Purpose / when: iCBT week 6. Changes the threatening meaning attached to tinnitus [source: Beukes et al.].
Steps: (1) Write out the current thoughts and associations about tinnitus ("it will drive me mad"; "it means my brain is damaged"). (2) Examine them with information from the education module and with E2. (3) Write alternative, neutral meanings ("a sound my auditory system makes, like background hum"). (4) Rehearse them daily.
Example language (illustrative): "What does the sound mean to you when it's at its worst?"
Watch for: Unresolved medical fears. Check the person has had an appropriate audiological and medical assessment.

F8. Tinnitus: focus exercises (mindful awareness)

Purpose / when: iCBT week 5, after relaxation practice. Trains flexible attention toward and away from sounds [source: Beukes et al.; the detailed content was not described in the protocol, [uncertain]].
Steps (synthesis): (1) After relaxing, rest attention on the breath. (2) Widen attention to all the sounds around, including the tinnitus, noticing without judging. (3) Shift focus between a neutral sound and the breath. (4) Return to the breath.
Example language (illustrative): "Let the tinnitus be one sound among many. You don't need to push it away."
Watch for: A rise in distress. Shorten the exercise and pair it with rapid relaxation.

F9. Tinnitus: exposure to tinnitus

Purpose / when: iCBT week 7. Reduces avoidance of and reactivity to the tinnitus itself [source: Beukes et al.].
Steps: (1) After relaxation, deliberately listen to the tinnitus for 5–10 min once daily. (2) Rate distress at the start and end. (3) Notice what happens without trying to change it. (4) Continue daily until distress during listening falls.
Example language (illustrative): "For these ten minutes, you go looking for the sound rather than running from it."
Watch for: Current suicidal thinking or severe distress. Stabilise and assess first (see section 5). Explain the rationale, obtain consent, and stop if the person becomes overwhelmed [synthesis].

F10. Tinnitus: graded exposure for sound sensitivity

Purpose / when: An optional iCBT module for sensitivity to everyday sound (hyperacusis-like avoidance) [source: Beukes et al.].
Steps: (1) List avoided everyday sounds and settings. (2) Rank them by discomfort. (3) Expose gradually to sounds that are not damaging and not annoying, starting low and for short periods. (4) Step up the level and duration. (5) Reduce earplug use in ordinary environments in steps [synthesis].
Watch for: Genuinely loud environments. Keep ear protection there, as part of safe listening (NICE NG155 1.1.4).

F11. Tinnitus: hearing tactics

Purpose / when: An optional iCBT module of communication advice for people with tinnitus plus hearing difficulty [source: Beukes et al.]. Specifics are my synthesis.
Steps: Face the speaker; reduce background noise; ask people to rephrase rather than repeat; tell others what helps; use captions; liaise with audiology about devices.
Watch for: Social withdrawal blamed on tinnitus that is actually driven by hearing loss.

F12. IBS-specific elements

Muscle relaxation and self-monitoring of stress–symptom links are taught first: in standard CBT phases 2–3 and minimal-contact session 1, with home study materials [source: IBSOS protocol]. Apply A2, D1 and D2.
Catastrophising about bowel symptoms ("if I get cramps on the train I'll be humiliated") is worked on with E2 and E3.
Symptom exposure and reducing control behaviour. An exposure-based CBT for IBS developed by Ljótsson and colleagues has patients deliberately approach feared bowel sensations and situations, and drop avoidance and control behaviours: restricted eating, toilet mapping, staying home. Not drawn on, and given here only as an orientation [uncertain]. In practice, build a hierarchy of avoided situations and work through it as in C6 [synthesis].
Watch for: Red-flag bowel symptoms (rectal bleeding, weight loss, change of pattern in older patients). These need medical review before exposure [synthesis]. Do not set dietary rules; leave diet to the gastroenterologist or dietitian.

G1. Acceptance and grief work

Purpose / when: Wherever loss of roles and identity is blocking engagement [source: VA Brief CBT-CP; NICE NG155 places ACT and MBCT within stepped tinnitus care].
Steps: (1) Name and normalise grief. The VA manual uses grief-stage ideas loosely as a framework, not a fixed sequence. (2) Distinguish acceptance (stopping the unwinnable fight for a cure in order to live well now) from resignation. (3) Link acceptance to valued goals (B3) and pleasant activity (C5).
Example language (illustrative): "Accepting this isn't giving in. It's taking back the energy you've spent fighting it and spending it on your life."
Watch for: Hopelessness that is presented as acceptance. Assess mood and suicide risk.

G2. Discharge planning, relapse prevention and the Pain Action Plan

Purpose / when: Session 11 or Module 6 (Brief CBT-CP); IBS minimal-contact session 4; tinnitus week 8 [source: guidebook Module 6; VA CBT-CP manual; IBSOS protocol; Beukes et al.].
Steps: (1) Look back: compare measures and goals then and now; ask which skills helped most. (2) Anticipate obstacles: list likely triggers or stressors, such as flares, busy periods or illness, and name the coping skill for each (relaxation, pacing, pleasant activities, support). (3) Build a flare plan: early warning signs; what to scale back and for how long; which skills to use; when to restart graded activity; when to seek medical help [synthesis: the guidebook has no formal flare plan]. (4) Write an hour-by-hour plan for the coming week, including practice. (5) Set new SMART goals for about 3 months and for 6–12 months. (6) Agree a booster session and an open door to return.
Example language (illustrative): "Flares will come. The question is whether you face them with a plan or start from zero."
Watch for: Treating the first setback as failure. Pre-name setbacks as expected.

G3. Booster session

Purpose / when: About one month after discharge. Review which skills are being used, troubleshoot problems, and refresh skills that have lapsed [source: VA CBT-CP manual].
Steps: Repeat the measures; review the action plan and what got in the way; rehearse one skill; update goals.
Watch for: Practice that has quietly stopped, and slow drift back into avoidance or boom-bust patterns.

5. Handling problems

Feeling invalidated ("you think it's in my head") [source: VA CBT-CP manual therapist considerations; VA Brief CBT-CP]. Say plainly that the pain is real, that the focus is coping and quality of life, and that medical care continues alongside. Many patients have felt unheard or labelled by past providers, so give time to that history before teaching. Illustrative: "You've been passed around a lot. I'm not replacing your doctors. I'm adding something they can't give you."

"I've tried everything" / resistance [source: VA CBT-CP manual; VA Brief CBT-CP]. Empathise with past disappointments, give education about chronic pain, and ask what there is to lose by trying something different. Use MI: reflect both sides of the ambivalence and elicit their own reasons for change. Don't argue.

Fixation on medication, scans or procedures [source: VA Brief CBT-CP; VA CBT-CP manual]. Listen and validate the frustration, refer medical questions to the prescriber or primary care, and return to the skills. Present it as one team. Do not comment on doses or drugs.

Non-adherence to home practice [source: VA CBT-CP manual (practice predicts outcome; early commitment and alliance predict adherence); remaining steps [synthesis]]. (1) Review practice at the start of every session, never skip it, and praise any partial attempt. (2) Find the specific barrier: forgot, didn't see the point, pain too bad, chaos at home. (3) Make the task smaller and link it to an existing routine. (4) Do the practice in session. (5) Recheck that the rationale makes sense to them. (6) Check the alliance (WAI) and repair it if needed.

Stuck (no change on measures) [source: VA Brief CBT-CP troubleshooting]. Check practice and goals, revisit modules, and add optional modules (sleep, exposure, trigger work). If skills are being applied and there is still no change, refer to a specialist pain service or behavioural medicine. [synthesis] Re-formulate: is the hidden driver fear-avoidance (add C6), boom-bust (tighten C1), untreated depression or PTSD (treat it or refer), a partner reinforcing disability (C3), or a disability claim or litigation creating mixed incentives (name it without judgement)?

Flares during treatment [source: VA CBT-CP manual (overactivity causes flares; pacing instead); guidebook]. Normalise flares and separate a transient overexertion flare from a stable change (see below). Use the flare plan: scale back but don't stop, keep pacing by time, use relaxation and coping statements, and restart the quota at a lower level [synthesis for the restart rule].

Worsening, new symptoms or red flags [source: VA CBT-CP manual; VA Brief CBT-CP; NICE NG155 1.2]. New radiating pain or new weakness not known to the medical team, sudden hearing loss, acute uncontrolled vertigo, new neurological signs, and (my addition [synthesis]) new red-flag bowel symptoms all go to prompt medical assessment. Pause exposure until cleared.

Suicide risk [source: VA Brief CBT-CP (assess safety first when worsening); NICE NG155 1.2.1 (crisis referral for high risk with tinnitus); details [synthesis] following standard practice]. Chronic pain, sleep loss and tinnitus distress raise risk. Ask directly about suicidal thoughts at intake and whenever measures worsen. Assess intent, plans, history and protective factors. Agree a written safety plan with warning signs, coping steps, people to contact and crisis lines. Do lethal-means counselling: secure storage or removal of stockpiled medications and firearms, with family involved where appropriate. Arrange urgent crisis-team referral when risk is high, and coordinate with the prescriber, given access to analgesics.

Overwhelm or high distress in session [synthesis]. Slow down, return to grounding and breathing, shorten the content, use one handout instead of three, and summarise often. For exposure, drop to a lower hierarchy item rather than stopping all exposure.

Ruptures [synthesis, consistent with the VA's alliance emphasis]. Common triggers: feeling pushed too hard on activity, homework felt as blame, or a sense you are siding with the doctors. Name the strain, ask for their view, take your share of responsibility ("I moved too fast on the exercise plan"), and renegotiate the task. Track it with the WAI.

Shifting or vague complaints [source: VA CBT-CP manual]. Point to the gains already made. Remind them the skills transfer to any new pain site. Send new pain to a medical provider. Let vague complaints pass without dwelling on them, or ask for specifics.

Pain behaviour in session (groaning, standing and pacing, long pain narratives) [source: VA CBT-CP manual; Wegener et al. 2011]. Allow position changes as part of pacing. Respond briefly and kindly, then return to the agenda, and give more attention to coping talk. Avoid both ignoring the patient and over-attending to the behaviour.

Family undermining change [source: VA CBT-CP manual]. A spouse who has become the carer may feel threatened by the patient's progress. Invite them to a session, validate their role, and give them a new one: coach and cheerleader (C3).

Exposure-specific problems [source: Vlaeyen et al. 2002 for the principles; responses [synthesis]]. Refusal: go lower on the hierarchy, model more, or have the patient do part of the movement. Safety behaviours (bracing, rushing, partial movement): name them and drop them in steps. A pain increase is read as damage: go back to "hurt is not harm", re-rate the harm expectancy, and look at what actually happened afterwards. Fear returns at home: add home tasks and involve family. Never use correct-posture instructions as reassurance.

Pacing turning into avoidance [synthesis]. If the active periods never lengthen, add planned small increases (C2) and check for fear-driven limits; if present, switch to exposure.

Headache-specific [synthesis unless tagged]. Frequent acute medication use: coordinate with the neurologist about medication-overuse headache before or alongside CBT. Trigger avoidance spreading (very narrow diet, darkness, social withdrawal): use the LCT logic to target avoidance [source: Martin et al. 2021 abstract]. Attacks during group sessions: agree in advance that the person may step out, practise their attack plan, and catch up.

IBS-specific [synthesis]. Embarrassment talking about bowel symptoms: use plain words, normalise, and ask matter-of-fact questions. Toilet-access fear blocks attendance: tell them where the nearest toilet is, offer phone or video sessions (the IBSOS minimal-contact format uses phone check-ins), and make attending sessions an early exposure task. Restrictive eating: do not add rules; refer to a dietitian, and screen for an eating disorder or ARFID.

Tinnitus-specific [source: NICE NG155 for referral and stepped care; responses [synthesis]]. "I just want it gone": acknowledge it, explain that habituation and reduced distress are realistic goals, and use reinterpretation (F7). Insomnia dominates: move the sleep work earlier and consider CBT-I. Digital programme not working: step up to group, then individual CBT, as NICE describes. Sound sensitivity: graded exposure (F10), keeping ear protection for genuinely loud settings.

Low literacy, cognitive impairment, older adults [synthesis; not addressed in the sources]. Use one skill per session, spoken rather than written homework, recorded relaxation, pictures, more repetition, and a carer as practice prompt. Brief CBT-CP's 30-minute module format suits limited attention.

Telehealth [synthesis; not addressed in the Brief manual pages]. All modules except therapist-modelled exposure and biofeedback move easily to video. For exposure by video, check the home space is safe, agree items in advance, and have the patient do the movements on camera.

Sources

Sources:

CBT-CP Therapist Manual (VA; Murphy, McKellar, Raffa, Clark, Kerns & Karlin). Part 1, therapist considerations, session structure and Session 1 are drawn on; later session text is not drawn on.
Brief CBT for Chronic Pain: Therapist Manual v2.0 (Beehler, Murphy, King & Dollar, 2021). Overview, Module 1 and troubleshooting were read.
Brief CBT-CP Patient Guidebook (VA, 2021)
NICE NG155: Tinnitus – assessment and management, Recommendations
IBS Outcome Study (IBSOS) protocol, NIDDK repository (Lackner et al.)
A CBT-based Internet Intervention for Adults With Tinnitus in the UK – protocol NCT02370810 (Beukes et al.)
Klan et al. (2022), migraine-specific integrative CBT vs relaxation, Frontiers in Neurology
Martin et al. (2021), Integrating headache trigger management strategies into CBT – IASP summary/abstract
Wegener, Wolfman & Haythornthwaite (2011), Psychological interventions for chronic pain (book chapter)
Vlaeyen, de Jong, Geilen, Heuts & van Breukelen (2002), Treatment of fear of movement/(re)injury in chronic low back pain: exposure in vivo, Clin J Pain 18(4)

Key source not drawn on: NICE NG193: Chronic pain (primary and secondary) in over 16s. Statements attributed to it are marked [uncertain].