Literacy Deficiencies Restrict Access to Cognitive-Behavioral Pain Therapy

ANAHEIM, March 6, 2018 – Although impressive scientific evidence shows that pain self-management programs based on cognitive-behavioral therapies (CBT) are effective, they would have greater utility and impact if simplified appropriately for persons with below average literacy skills and impaired cognitive function, according to a leading pain psychologist speaking at the American Pain Society Scientific Summit here.

In her research, Beverly Thorn, Ph.D., professor emerita of psychology, University of Alabama, investigates the psychosocial aspects of coping with chronic pain.  In a plenary session, she emphasized that biopsychosocial approaches to treating chronic pain have proven effective but they pose unique challenges and difficulties for disadvantaged populations. 

Thorn said pain disproportionately affects economically and socially disadvantaged populations, especially ethnic minorities.  They experience higher rates of chronic pain and pain-related disability, as well as comorbid depression and anxiety.  Literacy also is a disadvantage and hampers ability to participate in cognitive behavioral therapy (CBT).  She cited data showing that more than 30 million Americans function at a “Below Basic” literacy level and are capable of only simple, concrete literacy activities. 

“Deficits in literacy can limit a patient’s ability to understand and benefit from psychological pain treatments. Compounding the problem, however, is cognitive impairment associated with numerous medications often prescribed to patients with chronic pain,” said Thorn.  “Arguably, anyone dealing with a chronic, stressful medical condition would greatly benefit from simpler and more straightforward psychological treatment approaches.”

Thorn mentioned that the National Pain Strategy developed by Interagency Pain Research Coordinating Committee (IPRCC) at NIH advocates wider use of interdisciplinary pain management approaches, which include CBT. 

“Studies referenced in the National Pain Strategy show that psychosocial pain treatments work and are making a difference, but to significantly expand their use, and perhaps lower physician reliance on opioids, there is an urgent need for more user-friendly pain information with relevant and simplified pain facts presented during interactive discussions,” said Thorn.  “In this way, patients learn collaboratively with the healthcare provider instead of being a passive recipient of information and skills training.”

Thorn said dropout rates for CBT programs are as high as 35 percent.  Research shows that lower educational attainment, reading levels and income were the most significant predictors of failure to complete CBT.  Follow-up interviews revealed that participants with the lowest literacy levels appeared to have the greatest difficulty comprehending and being actively involved in CBT. 

Stigma also is an obstacle for many pain patients when CBT is recommended.  “Clinicians must simplify how they talk to patients about CBT.  Sometimes when a patient hears the doctor talk about how the brain influences pain, it can be misconstrued that your pain isn’t real and is all in your head,” said Thorn.  She added that healthcare providers must inform patients they can train the brain to close metaphorical gates that allow pain signals to pass into it. “This treatment rationale is simple and makes sense to patients who now talk about strategies they learn to become gate closers.”

Thorn added that brain imaging proves that psychological treatments result in lasting changes in brain structure and function and provide a neurophysiological basis for CBT and related therapies.  “Knowing that psychological methods are effective for pain management heightens the importance of removing socioeconomic, cognitive and literacy barriers that limit or prevent effective treatments within disadvantaged populations with chronic pain,” Thorn stated.

About the American Pain Society

Based in Chicago, the American Pain Society (APS) is a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.  APS is the professional home for investigators involved in all aspects of pain research including basic, translational, clinical and health services research to obtain the support and inspiration they need to flourish professionally.  APS strongly advocates expansion of high quality pain research to help advance science to achieve effective and responsible pain relief.  For more information on APS, visit