Multicomponent CBT for fibromyalgia and rheumatological pain

1. Introduction

Version followed: a composite with no single founder or manual. The component structure follows the APA Division 12 entry "Multi-component CBT for rheumatologic pain" (8 to 12 sessions; education, symptom self-management skills, lifestyle change and relapse prevention). For fibromyalgia (FM) it uses the manualised group CBT and operant behavioural treatment (OBT) of Thieme, Flor and Turk (2006), and the tailored CBT plus exercise programme of van Koulil, Evers and colleagues (2010). For arthritis pain it uses Keefe's pain coping skills training (PCST), in the 10-session form set out in Bennell et al.'s (2012) knee osteoarthritis protocol. The original German manuals and Keefe's own manual (Cognitive Behavioral Therapy for Arthritis Pain, Duke) are not drawn on; the steps below are reconstructed from published method descriptions. [source: Div12; Thieme et al. 2006; van Koulil et al. 2010; Bennell et al. 2012] [uncertain: manual-level detail]

This is a family of manualised programmes, not one branded therapy. The programmes combine pain education, cognitive and behavioural coping skills, operant work on pain behaviour, graded activity or exercise, and involvement of the partner. They are run by a psychologist, often with a rheumatologist, physiotherapist or social worker. The core idea of change is that persistent pain is kept going partly by learning and appraisal. Pain behaviours, avoidance and catastrophising are shaped and reinforced by the patient's own thinking and by the responses of partners and clinicians. People adapt by gaining control over the physical, emotional, cognitive and behavioural sides of their pain. Change comes from new mastery experiences (doing more than they predicted, with less pain than they predicted), from changed reinforcement of healthy versus pain behaviour, and from more flexible appraisals. These strengthen self-efficacy, so even where pain intensity changes little, its interference falls. [source: Div12; Thieme & Turk 2012; Thieme et al. 2006]

2. Framework

Formats in the sources [source: Div12; Thieme et al. 2006; van Koulil et al. 2010; Bennell et al. 2012; Thieme & Turk 2012]

Generic rheumatological-pain CBT (Div12): individual or small group, 8 to 12 sessions.
Thieme/Flor/Turk FM group CBT or OBT: 15 weekly 2-hour sessions in groups of five patients. Each group is co-led by an experienced psychologist and a rheumatologist, who have done a joint 2-day training. Spouses attend sessions 1, 5, 9 and 13. There is weekly homework for patients and spouses. The trial included only married women with a willing spouse.
Tailored CBT plus exercise for high-risk FM (van Koulil/Evers): groups of 8. There are 16 sessions, twice a week over about 10 weeks. Each session is 2 hours of CBT (psychotherapist plus social worker) followed by 2 hours of exercise (physiotherapists). Partners or another significant person attend sessions 3, 9 and 15. Homework takes about 1.5 hours a day. One booster session follows about 3 months later. The protocol differs for patients with a pain-avoidance pattern and those with a pain-persistence pattern.
Keefe PCST for arthritis pain: 10 sessions, each built around one skill with home practice that carries forward. In the Bennell trial it was delivered by physiotherapists alongside exercise.
Dose: Thieme and Turk report that studies with more than 20 treatment hours achieved long-term improvement. In their review, higher dose predicted better CBT outcome.

Phases (the sources describe content order, not formal phases; the phase labels and transition criteria are [synthesis])

Assessment, selection and engagement (intake, before session 1). Goals: confirm the medical diagnosis with the rheumatologist and exclude untreated inflammatory disease or major comorbidity. Screen distress. Identify the dominant pattern: pain-avoidance or pain-persistence (van Koulil); high cognitive maladaptation and affective distress, pointing to a CBT emphasis, or high pain behaviour, low function and a solicitous spouse, pointing to an OBT emphasis (Thieme). Recruit the partner. Move on when there is a shared formulation, a pattern classification and agreed goals [synthesis].
Education and a shared model (sessions 1 to 2). Goals: give the stress-tension-pain circle (CBT), the learning and pain-memory model (OBT) or gate control (PCST). Introduce the patient's active role. Start self-monitoring. Move on when the patient can describe their own cycle with a personal example and is keeping diaries [synthesis].
Skill acquisition (roughly sessions 2 to 10). Goals: relaxation; activity regulation (quota-based increase for avoiders, pacing for persisters); operant work on pain behaviour; cognitive restructuring; distraction; problem solving; assertiveness; exercise. Partner sessions are placed at intervals through this phase. Move on when each skill is practised at home at the agreed frequency and shows some effect on diary ratings or activity [synthesis].
Application and generalisation (final sessions). Goals: apply the combined skills to the patient's own high-risk situations and build coping plans; gradually withdraw therapist prompting. Move on when the patient can plan independently for upcoming difficult situations [synthesis].
Maintenance and relapse prevention (last session plus a booster about 3 months later). Goals: identify early warning signs, write a lapse plan, consolidate goals. [source: Bennell et al. 2012 session 10; van Koulil et al. 2010 booster]

Session format. Review homework, then introduce and practise the new topic in the group, then assign new homework [source: van Koulil et al. 2010]. In the exercise programme, each session includes relaxation, aerobic work, and either hydrotherapy or strength, flexibility and functional walking [source: van Koulil et al. 2010].

3. Guiding principles

[source: Div12; Thieme & Turk 2012; Thieme et al. 2006; van Koulil et al. 2010; Bennell et al. 2012; one-line practical meanings are synthesis]

Pain has physical, emotional, cognitive and behavioural sides; the aim is control over them, not cure. Set goals in function, mood and participation, not only pain scores.
The patient has an active role, and the model is shared. Do not start skills until patient and clinician agree on the rationale.
Pain persistence partly reflects learning. Pain behaviours, avoidance and medication use are maintained by their consequences, so look for what each behaviour gets or avoids for the patient.
Avoidance is a powerful reinforcer and hard to extinguish (Thieme & Turk's point). Expect avoidance to come back after setbacks, and plan repeated exposure.
Work to goal, not work to pain. Activity and exercise stop at a preset quota, not when pain rises, and the quota rises gradually.
Medication by the clock, not by pain. Analgesics are taken at fixed times and reduced gradually under a physician's plan, never taken in response to pain reports.
Reinforce healthy behaviour and do not reinforce pain behaviour. Therapist, group and partner attend to and praise pain-incompatible behaviour and give little attention to pain displays.
Every clinician applies learning principles. Prescribers and other team members avoid unintentionally rewarding symptom reports (for example, prescribing in response to complaints).
Tailor to the patient's pattern. Avoiders increase activity regardless of symptoms; persisters first learn to regulate overactivity and rest, and only then build up.
Involve significant others. Partners learn to reinforce healthy behaviour and to reduce solicitous responses.
Learning happens through self-monitoring, rehearsal and social reinforcement. Every skill is practised in session and at home and is recorded.
Catastrophising is always a target. Identify both stress-related and pain-related catastrophising in every patient.
Build self-efficacy through mastery. Arrange experiences in which the patient changes their own pain perception or does more than predicted, then make the success explicit.
Exercise is part of the treatment. It trains bodily perception, increases activity and reduces avoidance and medication use.
Change is gradual and systematic. Every increase is small, planned and recorded.
Dose and maintenance matter. Aim for enough contact hours, use booster sessions and plan for relapse from the start.
Patients are heterogeneous. Match the emphasis (cognitive versus operant, avoidance versus persistence protocol) to the patient's profile, and review the match if progress stalls.

4. Intervention inventory

The interventions are grouped as follows: A, assessment and education; B, operant and behavioural; C, activity and exercise; D, relaxation and attention; E, cognitive; F, interpersonal; G, consolidation and team. Each item is tagged with the programme it comes from. All example language is illustrative and is not taken from the manuals.

A1. Intake assessment and pattern classification

Purpose / when: Before treatment, to select patients and choose the emphasis. [source: van Koulil et al. 2010; Thieme et al. 2006; Thieme & Turk 2012]
Steps:
1. Confirm with the rheumatologist that the FM or arthritis diagnosis is current. Note any comorbidity that would exclude the patient: severe physical or psychiatric illness, or untreated inflammatory disease when running an FM group.
2. Screen negative mood and anxiety. The van Koulil programme specifically targeted patients with raised distress.
3. Use a semistructured interview to classify the daily pattern. Pain-avoidance: rests, withdraws and stops activities when in pain. Pain-persistence: carries on regardless, overdoes it, then crashes. The van Koulil team added a validated pain-coping questionnaire subscale on resting when in pain, and the therapist's judgement decided cases where the two disagreed. (The instrument is licensed; its items are not reproduced here.)
4. For an operant versus cognitive emphasis, rate observable pain behaviour, physical impairment, physician visits, how solicitous the spouse is and how much the patient catastrophises (which favour OBT), against affective distress and maladaptive cognitions with few pain behaviours (which favour CBT). The authors present this as a hypothesis, not a validated rule.
5. Confirm that a partner or significant other is willing to attend some sessions.
6. Agree on a draft formulation and on 2 to 4 functional goals.
Example language (illustrative): "When the pain flares, what do you usually do in the next hour? And what does your partner do?"
Watch for: Patients with a mixed pattern (for example, persistence at work and avoidance at home); classify by the dominant pattern and note the exception [synthesis]. Intake education can itself produce change; van Koulil's waiting-list patients improved slightly.

A2. Education: the stress-tension-pain circle (CBT emphasis)

Purpose / when: Session 1 of the cognitive emphasis, to give a model linking stress, muscle tension, automatic thoughts (especially catastrophising) and pain perception. [source: Thieme et al. 2006; Thieme & Turk 2012]
Steps:
1. Draw the circle: stressor, then appraisal (for example, "this will never stop"), then tension and arousal, then more pain, then more stress.
2. Ask each group member for one recent personal example and map it onto the circle.
3. Show where each upcoming skill breaks the circle: relaxation at tension, restructuring at appraisal, problem solving at the stressor.
4. Give a diary of situations, thoughts, tension and pain as homework.
Example language (illustrative): "Your pain is real. What we can change is how much stress and tension keep feeding it."
Watch for: The patient hearing "it's psychological". Validate the reality of the pain explicitly. The model is working when patients bring their own examples back mapped onto the circle.

A3. Education: the learning model and pain memory (OBT emphasis)

Purpose / when: Opening sessions of OBT. Three teaching steps: understanding pain, detecting pain behaviours, separating pain behaviour from healthy behaviour. [source: Thieme & Turk 2012]
Steps:
1. Understanding pain: explain that the sensory, emotional, cognitive and behavioural parts of pain are stored together as a "pain memory". Fear, sadness and pain behaviours become conditioned to pain, and these links can be weakened (extinguished) through new experience.
2. Detecting pain behaviours: list them with the patient. Examples: grimacing, guarding, moaning, talking about pain, resting, medication taking, extra doctor visits, avoidance, and low mood or anxiety displays.
3. Separating pain behaviour from healthy behaviour: for each life area (home, partner, work, leisure, health care), sort behaviours into pain behaviours and healthy behaviours. Note who responds to each and how: spouse, children, friends, physicians, and the patient's own catastrophising.
Example language (illustrative): "Let's look at what happens right after you rub your back and sigh. Who notices, and what do they do?"
Watch for: Shame or defensiveness. Frame pain behaviours as learned, understandable and mostly outside awareness; Thieme and Turk note that patients often do not know their behaviour is being shaped. It is working when the patient can name their own maintaining consequences.

A4. Rationale via gate control (PCST)

Purpose / when: PCST session 1, to explain why coping skills can change the pain experience. [source: Bennell et al. 2012]
Steps: Explain in plain terms that the nervous system can turn pain signals up or down, and that tension, mood and attention open or close the "gate". Then link each skill in the programme to closing the gate. Introduce progressive muscle relaxation (D1) in the same session.
Example language (illustrative): "Each skill we practise is a way of turning the volume down a notch."
Watch for: Over-promising. Present the skills as reducing the pain's impact, not as eliminating it [synthesis].

A5. Self-monitoring

Purpose / when: Throughout, as the basis of every skill. [source: Div12; Bennell et al. 2012; van Koulil et al. 2010]
Steps: Agree on one simple daily record per phase: pain and tension ratings with relaxation practice; activity with rest periods; situations and thoughts (thought record); pain versus healthy behaviours. Review it at the start of every session before any new material, and reinforce completion.
Example language (illustrative): "Let's start with your diaries. What did you notice this week?"
Watch for: Diaries that become pain-focused rumination; shift what is recorded towards activity and skill use [synthesis].

B1. Video feedback of pain expressions (OBT)

Purpose / when: OBT, early skill phase, to make the patient aware of pain behaviours that happen outside awareness. [source: Thieme et al. 2006]
Steps (procedural detail [synthesis]; the source names only the technique):
1. Get consent to record.
2. Record the patient during an ordinary in-session task, such as walking, sitting down or describing their week.
3. Replay the recording with the patient. Have them mark each visible or audible pain behaviour, then compare with the therapist's and group's observations.
4. Pick 1 to 2 target behaviours to reduce and a healthy alternative for each.
5. Re-record later to show change.
Example language (illustrative): "Watch this clip with me. What do you think someone meeting you for the first time would notice?"
Watch for: Humiliation. Keep the tone curious, start with the patient's own observations, and never show a recording to the group without consent.

B2. Contingent reinforcement and the red and green card plan (OBT)

Purpose / when: Throughout OBT, to strengthen pain-incompatible behaviour and weaken pain behaviour. [source: Thieme et al. 2006; Thieme & Turk 2012]
Steps:
1. Agree with each patient which pain behaviours and which healthy behaviours are targeted.
2. In the group, patients, spouses and group members signal displayed pain behaviour with a red card and healthy behaviour with a green card.
3. Therapists praise healthy behaviour immediately and specifically, and give little attention to pain displays.
4. Carry the plan home: the spouse reinforces healthy behaviour and reduces solicitous responses.
Example language (illustrative): "You stood the whole round of discussion without stopping to rub your neck. That's a green card."
Watch for: The source lists "punishment of pain behaviours" among the OBT techniques. In current practice, keep red cards light and agreed in advance, and lean on reinforcement of healthy behaviour and withdrawal of attention rather than anything aversive [synthesis]. Stop the cards for any patient who experiences them as shaming. It is working when healthy behaviours rise in the diaries and on video.

B3. Role-play to reduce pain behaviour and build healthy behaviour (OBT)

Purpose / when: OBT skill phase, to rehearse alternatives in everyday situations. [source: Thieme et al. 2006]
Steps: Pick a recurring scene, such as greeting a partner after work or a doctor's appointment. Play it once as usual. Identify the pain behaviours and their payoff. Agree on a healthy alternative, such as saying what you would like to do together instead of describing the pain. Replay it with group feedback and green cards. Set the new behaviour as homework.
Example language (illustrative): "Let's run the doctor's visit again, this time opening with what you managed this month."
Watch for: Patients suppressing all pain communication. The aim is fewer pain displays and more active behaviour, not hiding real medical changes. Agree on how new or different symptoms are reported [synthesis].

B4. Time-contingent medication and gradual reduction (OBT; also in CBT)

Purpose / when: After assessment, coordinated by the physician, to stop analgesic intake reinforcing pain reports. [source: Thieme et al. 2006; Thieme & Turk 2012]
Steps:
1. The physician co-therapist reviews the current regimen.
2. Agree on fixed intake times in place of as-needed use.
3. Agree on a gradual reduction plan led by the physician (no dosing guidance here).
4. Record intake in the diary.
5. Review it at each session and reinforce adherence.
Example language (illustrative): "From now on your tablets go by the clock, not by how the pain feels. That way the pain doesn't decide."
Watch for: Withdrawal effects or rebound pain. Any change is managed by the prescriber, never by the psychologist alone [synthesis].

B5. Team contingency management

Purpose / when: Ongoing, so that the treatment system does not undo the operant work. [source: Thieme & Turk 2012]
Steps: Brief all prescribers and the team that responses to pain reports (prescribing on complaint, extra appointments, sick notes) can reinforce symptoms. Agree on scheduled appointments in place of pain-triggered ones. Agree on how the team will respond to new symptoms (assess them medically) as distinct from habitual complaints (redirect to goals) [synthesis].
Watch for: Mixed messages between team members. Hold a short team meeting before the group starts; Thieme's teams planned in advance how to handle motivation problems and non-adherence.

C1. Goal setting across life domains

Purpose / when: Early in treatment, then revisited each session. Avoiders set goals for increasing activity; persisters set realistic goals. [source: van Koulil et al. 2010; Bennell et al. 2012 session 4; Div12]
Steps:
1. Ask for valued activities given up or overdone in each domain: household, work, social, leisure, partner.
2. Turn each into a concrete, observable goal, and break it into weekly steps.
3. Write the steps into the activity plan and review them at each session.
4. For persisters, check that goals are realistic and include planned rest.
Example language (illustrative): "What would you be doing in three months if the pain had less say?"
Watch for: Goals framed as "less pain". Redirect them to behaviour. Goals that are too large lead to failure and dropout [synthesis].

C2. Quota-based graded activity (work to goal) for the avoidance pattern

Purpose / when: The core of the pain-avoidance protocol and of OBT, to raise activity in fixed steps whatever the symptoms. [source: Thieme & Turk 2012; van Koulil et al. 2010]
Steps:
1. Measure a baseline for the chosen activity over several days, for example minutes walked or tasks done before stopping.
2. Set the starting quota just below the baseline.
3. Raise the quota by small preset steps.
4. The patient stops when the quota is reached, not when pain rises, and does not exceed it on good days.
5. Record completion, and praise completion rather than pain tolerance.
Example language (illustrative): "Today's target is the number we agreed. Stop when you hit it, even if you feel you could do more."
Watch for: Patients working to pain on bad days or doing too much on good days. It is working when activity rises steadily and the expected flare is smaller than predicted (corrective feedback).

C3. Activity pacing and activity-rest cycling for the persistence pattern

Purpose / when: The first focus of the persistence protocol (regulate before building up), and PCST session 3. [source: van Koulil et al. 2010; Bennell et al. 2012]
Steps:
1. From the diary, identify boom-and-bust episodes.
2. Set an activity period shorter than the point where pain usually forces a stop.
3. Follow it with a short planned rest or change of activity, timed by the clock and not by pain.
4. Repeat the cycle through the task.
5. Once the pattern is stable, lengthen the activity periods gradually.
6. Build a balanced daily plan that mixes obligations, rest and pleasant activity.
Example language (illustrative): "Let's try 20 minutes of gardening, then sit down for five before the pain tells you to. That's you deciding, not the pain."
Watch for: Persisters feeling guilty about resting, or treating rest as failure; link this to cognitive restructuring (E2). Persisters may drop the plan once they feel better [synthesis]. Interval lengths in Bennell's protocol are set individually; no standard values were found.

C4. Graded exposure in vivo for pain-related fear

Purpose / when: For patients who avoid specific movements or activities out of fear of harm or flare, particularly avoiders. Named as part of the avoidance protocol and in Thieme and Turk's review (citing Vlaeyen). [source: van Koulil et al. 2010; Thieme & Turk 2012] [uncertain: the FM-specific exposure procedure]
Steps ([synthesis] following standard graded exposure practice):
1. Get medical clearance that the feared activities are safe for this patient.
2. Build a hierarchy of feared activities, rated for expected harm or pain.
3. Before each exposure, record the patient's prediction of pain, fatigue and harm.
4. Carry out the activity in session (with the physiotherapist if possible), then outside.
5. Compare the result with the prediction, which Thieme and Turk call corrective feedback.
6. Move up the hierarchy as fear ratings drop.
Example language (illustrative): "Before you lift the basket: how bad do you expect the pain to be tomorrow, from 0 to 10? We'll check tomorrow."
Watch for: Consent and safety: explain the rationale and get agreement for each step, and stop with any new or unexplained symptom. Contraindications: inflammatory flare or unstable joint disease in arthritis patients (the activity must be cleared by the rheumatologist) [synthesis]. It is working when predictions shrink and avoided activities come back.

C5. Pleasant activity scheduling

Purpose / when: PCST session 4; part of Div12 symptom self-management. Lifts mood and gives reinforcers that compete with pain behaviour. [source: Bennell et al. 2012; Div12]
Steps: List activities the patient enjoyed or values. Schedule three a week (the PCST homework) and link them to activity-rest cycling and relaxation mini-practices. Rate enjoyment and mastery afterwards.
Example language (illustrative): "What used to make a week feel like your week?"
Watch for: Persisters turning pleasant activities into obligations or overdoing them; pace them too.

C6. Integrated exercise training

Purpose / when: A fixed part of OBT and of the van Koulil programme. It trains bodily perception, raises activity, and reduces avoidance and medication use. [source: Thieme & Turk 2012; van Koulil et al. 2010]
Steps:
1. A physiotherapist runs the exercise block after the CBT block.
2. Each block includes relaxation; aerobic work (for example, cycling or gymnastics); and either hydrotherapy or strength, flexibility and functional walking.
3. Progress follows a systematic, gradual plan set individually: work to goal for avoiders, a paced plan for persisters.
4. The patient does daily home practice.
5. The psychologist and physiotherapist use the same language about pain and quotas.
Example language (illustrative): "The plan sets the amount. Pain afterwards is expected and isn't a sign of damage."
Watch for: Overtraining in persisters and dropout in fearful avoiders. No intensity targets are given here; they are set individually by the physiotherapist.

D1. Progressive muscle relaxation (PMR)

Purpose / when: PCST session 1; the relaxation component of FM CBT, practised during and between sessions. Reduces tension in the stress-tension-pain circle. [source: Bennell et al. 2012; Thieme et al. 2006; Div12]
Steps:
1. Seat the patient comfortably.
2. Work through muscle groups in a fixed order: tense each gently (not to pain), notice the tension, release it, and notice the contrast for longer than the tensing.
3. Finish with whole-body awareness, and ask for tension and pain ratings before and after.
4. Provide a recording, and set practice twice a day.
Example language (illustrative): "Tighten your hands just enough to feel it, not to hurt. Hold... and let go. Notice the difference."
Watch for: Tensing that provokes FM tender points or arthritic joints. Use gentle tension or release-only work for those areas [synthesis]. Some patients feel anxious when relaxing; keep their eyes open and sessions short.

D2. Relaxation mini-practices

Purpose / when: PCST session 2, to carry relaxation into daily life. [source: Bennell et al. 2012]
Steps: Teach a brief version of under a minute: a slow breath, a scan for tension, release. Attach it to frequent cues such as phone calls, red lights or kettles. Aim for ten or more a day and tally them.
Example language (illustrative): "Every time you put the kettle on: one slow breath, drop your shoulders."
Watch for: It is working when patients start using mini-practices without prompting during activity-rest cycles.

D3. Pleasant imagery

Purpose / when: PCST session 7; a distraction and relaxation technique. [source: Bennell et al. 2012]
Steps: After relaxation, guide the patient to imagine a pleasant, detailed scene using all the senses. Let them choose and rehearse their own scene. Set practice twice a day.
Example language (illustrative): "Pick a place you've felt calm. What do you see first? What can you hear?"
Watch for: Scenes that trigger grief for a lost activity; let the patient choose another scene.

D4. Attention-diversion techniques

Purpose / when: PCST sessions 7 and 8 (counting backwards, a focal point, auditory stimulation); stress reduction in FM CBT. [source: Bennell et al. 2012; Thieme & Turk 2012]
Steps: Teach each method briefly in session. Counting backwards: a slow, effortful count. Focal point: hold attention on an external object and describe its detail. Auditory: attend fully to music or sound. Rate pain or distress before and after. Set three uses a week and log which works for this patient.
Example language (illustrative): "Look at that picture and tell me everything about it, as if I can't see it."
Watch for: Distraction used as avoidance of necessary activity. Use it during activity, not instead of it [synthesis].

D5. Stress-response regulation (biofeedback, breathing, cardiovascular training)

Purpose / when: Proposed by Thieme and Turk for FM subgroups with abnormal stress responses (heart-rate and blood-pressure patterns). [source: Thieme & Turk 2012] [uncertain: the authors state this needs future study; not a standard programme component]
Steps: If used, train slow breathing with heart-rate feedback where equipment exists, alongside the aerobic exercise block.
Watch for: Present this as experimental.

E1. Spotting automatic thoughts and catastrophising

Purpose / when: PCST session 5. In FM CBT, Thieme and Turk call identifying catastrophising "indispensable", covering both stress-related and pain-related forms. [source: Bennell et al. 2012; Thieme & Turk 2012]
Steps:
1. Teach the sequence: an event leads to an automatic thought, which leads to emotional, bodily and behavioural consequences.
2. Work through a recent pain episode with the patient as an example.
3. Introduce a daily thought record with columns for situation, thought and consequence.
4. In the group, help members label recurrent themes: magnifying ("this is unbearable"), helplessness ("nothing I do matters") and rumination.
Example language (illustrative): "When the pain spiked on Tuesday, what went through your mind in that first second?"
Watch for: Patients recording only pain ratings. Prompt them for the exact words of the thought. It is working when patients catch thoughts as they happen, not only afterwards.

E2. Cognitive restructuring (Socratic dialogue and group challenge)

Purpose / when: PCST session 6; the core of FM CBT. Replace stress-related and catastrophic appraisals with active, coping-oriented ones, such as pacing and building endurance. [source: Thieme et al. 2006; Thieme & Turk 2012; Bennell et al. 2012; van Koulil et al. 2010 persistence protocol]
Steps:
1. Take one recorded thought.
2. Use Socratic questions: evidence for and against, past experience, what you would tell a friend, what helps you act.
3. In the group, the therapist names the maladaptive thought. Group members challenge it and offer other interpretations (the Thieme format).
4. The patient writes a balanced alternative and rates how much they believe it.
5. Set daily practice of replacing the thought.
6. For persisters, target "I must finish no matter what" and guilt about resting. For avoiders, target "activity will damage me".
Example language (illustrative): "You said 'I'll be in bed for a week'. How many times has that actually happened after a walk this month?"
Watch for: Arguing the patient out of real pain; target the appraisal, not the sensation. It is working when belief in catastrophic thoughts drops and the alternative thoughts come with action.

E3. Calming and coping self-statements

Purpose / when: PCST session 6, to give a ready replacement thought for high-pain moments. [source: Bennell et al. 2012]
Steps: Together with the patient, write 3 to 5 short statements in their own words, covering preparing for pain, coping during a spike and praising themselves afterwards. Put them on a card or phone and rehearse them while relaxed, then during activity.
Example language (illustrative): "I've handled flares before. One step at a time."
Watch for: Statements that are too positive to believe; the patient must find them credible.

E4. Structured problem-solving training

Purpose / when: PCST session 7; FM CBT, to address anxiety, helplessness and depression; Div12 lifestyle component. [source: Bennell et al. 2012; Thieme et al. 2006; Thieme & Turk 2012; Div12]
Steps (standard sequence [synthesis] where the sources only name the technique):
1. Define one concrete problem.
2. Brainstorm options without judging them.
3. Weigh the pros and cons of each.
4. Choose one and plan the steps.
5. Try it and review the result.
6. Set one problem-solving task a day (the PCST homework).
Example language (illustrative): "Let's pick one thing that went wrong this week and give it the full treatment."
Watch for: Patients choosing "the pain" as the problem. Pick a pain-related practical problem instead, such as shopping or a work schedule.

E5. Drawing on past successes (well-being and control strategies)

Purpose / when: FM CBT, to build active coping and self-efficacy from the patient's own history. [source: Thieme & Turk 2012]
Steps: Ask for times the patient coped well or felt in control despite pain, and draw out what they did. Turn that into a strategy for the present. After each in-session success (for example, lower pain ratings after relaxation), name the success as their own doing.
Example language (illustrative): "Your pain went from 7 to 5 in that exercise. What did you do that made the difference?"
Watch for: Patients crediting the therapist. Attribute the change back to the patient's skill.

E6. Stress management

Purpose / when: FM CBT and the Div12 lifestyle component, to reduce the stress input to the stress-tension-pain circle. Thieme and Turk give distraction and relaxation as the main stress-reduction techniques. [source: Thieme & Turk 2012; Div12]
Steps: Identify the main stressors from the diaries. For each, decide whether it can be changed (problem solving) or not (relaxation, distraction, restructuring). Build a personal stress plan.
Watch for: Stressors outside the patient's control, such as finances or caregiving. Consider social-work input; the van Koulil programme had a social worker co-leading.

F1. Assertiveness and social-skills training

Purpose / when: OBT's "assertive, pain-incompatible behaviour" training and the assertive social skills module of the persistence protocol. Helps patients ask for help, say no and get needs met without pain displays. [source: Thieme et al. 2006; Thieme & Turk 2012; van Koulil et al. 2010]
Steps:
1. Identify situations where the patient either overcommits (persisters) or uses pain to decline or get help.
2. Model a direct request or refusal, for example: "I'll do the first half and need you to do the rest."
3. Role-play it with group feedback.
4. Set one real-life practice as homework.
Example language (illustrative): "Try saying what you need without mentioning the pain at all, and see how it lands."
Watch for: Partners who push back. Rehearse responses in a partner session.

F2. Partner (spouse or significant-other) sessions

Purpose / when: Thieme: spouses attend sessions 1, 5, 9 and 13, with weekly homework for spouses. van Koulil: sessions 3, 9 and 15. Goal: partners reinforce healthy behaviour and ignore or reduce attention to pain behaviour. [source: Thieme et al. 2006; Thieme & Turk 2012; van Koulil et al. 2010]
Steps:
1. Explain the learning model to partners, including how caring responses (taking over tasks, asking about pain) can unintentionally maintain disability.
2. Each couple identifies their own patterns of pain behaviour followed by a solicitous response.
3. Agree on alternatives: notice and praise activity, and offer company in an activity in place of taking over.
4. Give partners homework, such as recording healthy behaviours they noticed.
5. Review progress at the next partner session.
Example language (illustrative), to the partner: "Your care is clearly real. We're asking you to aim it at what she's doing, not at the pain."
Watch for: Partners feeling blamed, and patients feeling abandoned. Frame the change as a shift in where support goes, not a withdrawal of support. Screen for relationship conflict or abuse first: the Thieme trial notes that about 40% of FM patients report high interpersonal distress. Where there is no partner, use a friend or family member, or leave this component out [synthesis].

G1. Applying coping skills to problem situations

Purpose / when: PCST session 9, the generalisation step. [source: Bennell et al. 2012]
Steps: The patient lists upcoming difficult situations, such as a family event, a work deadline, travel or weather changes. For each, they write a coping plan that combines skills (pacing, mini-practices, coping statements, problem solving, assertive requests). Rehearse one plan in session.
Example language (illustrative): "Your daughter's wedding is in six weeks. Let's build the plan for that day now."
Watch for: Plans that rely on a single skill; aim for at least three [synthesis].

G2. Relapse prevention and booster session

Purpose / when: PCST session 10; van Koulil booster about 3 months after the programme; Div12 maintenance component. [source: Bennell et al. 2012; van Koulil et al. 2010; Div12]
Steps:
1. Distinguish a lapse (a temporary flare or slip back into old patterns) from a relapse.
2. List personal early warning signs, such as stopping relaxation, a rise in rest or overwork, or a catastrophic thought coming back.
3. Write a lapse plan: which skills to restart, how to reset quotas temporarily, and whom to contact.
4. Review goals achieved and set goals for the next 3 months.
5. At the booster, review the plan and consolidate goals.
Example language (illustrative): "A flare is not starting over. It's the moment to open this plan."
Watch for: All-or-nothing conclusions after a first flare; normalise flares in advance.

G3. Homework system and session structure

Purpose / when: Every session. Home practice is the main way skills are learned; in PCST each assignment carries forward. [source: van Koulil et al. 2010; Bennell et al. 2012; Thieme et al. 2006]
Steps: Open each session with a homework review and reinforce effort specifically. Introduce one topic. Practise it in session. Assign specific homework (what, how often, how recorded), and keep earlier skills going. In Thieme's programmes, spouses also have homework.
Watch for: See non-adherence in section 5. Thieme reported low rates of missed homework (around 5%), with the team planning in advance how to manage non-adherence.

5. Handling problems

The sources say little here. Thieme's teams planned responses to motivation problems and non-adherence in advance, but the published papers do not describe them. van Koulil reports dropout reasons: treatment elsewhere, new physical illness, pregnancy and lack of sustained motivation. Avoidant dropouts had more pain and a higher FM impact. Unless tagged otherwise, everything below is [synthesis]. [source: Thieme et al. 2006; van Koulil et al. 2010; Thieme & Turk 2012]

"You're saying it's in my head" (the commonest early rupture). Validate first: FM and arthritis pain are real, and the programme works on the parts of pain the patient can influence. Use the patient's own diary example of stress raising their pain. Bring in the rheumatologist co-therapist to show medical and psychological care working together; Thieme's model of physician co-leadership supports this.
Stuck: no change in activity after 3 to 4 sessions. Re-check the pattern classification, since a persister may have been treated as an avoider or vice versa. Check that quotas were set below baseline. Look for hidden reinforcement of rest at home or from health care, such as a solicitous partner or as-needed medication. Thieme and Turk link OBT response to high pain behaviour and a solicitous spouse, so consider shifting to a stronger operant emphasis.
Stuck: activity rises but distress stays high. Shift the emphasis towards cognitive work (E1 to E5). Screen for depression, anxiety disorder or trauma that needs separate treatment.
Flare during the programme. Normalise it in advance. Temporarily lower quotas but do not stop; keep relaxation going; use the lapse plan (G2). Get a medical review for any new or different symptoms, and for inflammatory flares in RA, which may need treatment rather than coping.
Post-exercise pain leading to dropout (fearful avoiders). Thieme and Turk note that anticipatory fear drives premature termination of physical therapy. Use explicit pain predictions and compare them with outcomes (C4), lower the starting quota, and keep psychologist and physiotherapist messages aligned. [source: Thieme & Turk 2012]
Overwhelm (too many skills or too much homework). van Koulil's homework load was about 1.5 hours a day. For overwhelmed or very fatigued patients, prioritise one behavioural and one relaxation task, and add the rest as each becomes routine. Check whether fatigue reflects poor sleep. Sleep is not covered in the sources: consider standard CBT-I strategies or a referral [uncertain].
Non-adherence with homework. Review the barriers in session: whether the task was unclear, too large, or the rationale was not accepted. Shrink the task. Practise the first instance in session. Get partner support. Reinforce any partial completion. Do not reinforce excuses that centre on pain; respond with problem solving.
Medication reduction resisted, or a rebound. Medication changes are the prescriber's decision, never the therapist's. Keep the schedule time-contingent and slow the reduction rather than abandoning it. Coordinate any change with the prescribing physician.
The red and green card system feels shaming. Stop the red cards for that person and keep only green-card reinforcement; Thieme's description lists punishment of pain behaviours, which needs care in current practice. Debrief privately.
Partner problems. If the partner is critical or hostile rather than solicitous, operant withdrawal of attention may increase isolation; shift to communication and assertiveness work, or couple therapy. If there is any abuse, follow safeguarding procedures before continuing partner sessions. Patients without a partner can nominate another significant other (van Koulil allowed this).
Group problems. A member who dominates with pain talk: redirect warmly to coping ("What did you try?") and reinforce coping talk. Competitive comparison of symptoms: set a group norm early that the group talks about what members do, not how bad it is.
Ruptures over the persistence protocol ("you're telling me to do less"). Present pacing as a way to do more over the week, and use the patient's own boom-and-bust record as evidence.
Suicidal ideation (raised in chronic pain with depression). Assess risk with standard practice at intake and whenever mood drops. Include lethal-means counselling on safe storage of stockpiled medication, with removal or reduced supply coordinated with the prescriber. Refer for specialist care if risk is significant.
Diagnostic overshadowing. In arthritis especially, new joint swelling, fever or a neurological sign needs medical assessment, not coping skills. Keep a clear route back to the rheumatologist.
Poor fit after reassessment. If the patient has severe psychiatric comorbidity, is in other psychological treatment, or lacks the motivation to take part (all exclusions in van Koulil), treat that first or defer the group. [source: van Koulil et al. 2010]

Sources

Sources:

Further reading (not drawn on):

Bernardy K, Klose P, Welsch P, Häuser W (2017/2018). Cognitive behavioural therapies for fibromyalgia. Cochrane Database Syst Rev CD009796 (the job's key source; blocked) [uncertain].
Flor H, Turk DC (2011). Chronic Pain: An Integrated Biobehavioral Approach. IASP Press.
Fordyce WE (1976). Behavioral Methods for Chronic Pain and Illness. Mosby.
Turk DC, Meichenbaum D, Genest M (1983). Pain and Behavioral Medicine: A Cognitive-Behavioral Perspective. Guilford.
Keefe FJ, Beaupre PM, Gil KM (1997). Group therapy for patients with chronic pain. In Gatchel RJ, Turk DC (eds), Psychological Treatments for Pain: A Practitioner's Handbook. Guilford.
Keefe FJ. Cognitive Behavioral Therapy for Arthritis Pain (treatment manual, Duke University; not drawn on).
Vlaeyen JWS et al. (2001). Graded exposure in vivo for pain-related fear. In Turk DC, Gatchel RJ (eds), Psychological Approaches to Pain Management. Guilford.
Thieme K, Gromnica-Ihle E, Flor H (2003). Operant behavioral treatment of fibromyalgia: a controlled study. Arthritis Rheum 49:314-320.

← Previous · II-121CBT for chronic pain, chronic low back pain, chronic headache, IBS and tinnitus Next · II-123 →Pain reprocessing therapy