Psychological treatment.
The power of your brain.
Mind & behaviour
ACP · WHO · Lancet Rheumatol 2025
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
For chronic back pain, psychological treatments are among the few approaches where there is still something to measure a year later. That is not so strange: pain is produced by your brain, and thoughts, fear and stress have a direct influence on it. Do set the right expectation, though: the effects are real and they last, but they are small.
Cognitive Behavioural Therapy (CBT)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
CBT is the most researched psychological treatment for chronic pain. It targets changing negative thought patterns (catastrophizing, fear-avoidance) and behaviour that maintains pain.
What does it involve?
- 6-12 sessions with a psychologist or trained therapist
- Identifying and challenging unhelpful thoughts about pain
- Graded exposure to feared activities
- Relaxation techniques and stress management
- Activity planning and pacing
Evidence: The ACP (2017) recommends CBT for chronic back pain, and it is one of the few treatments with demonstrated benefit one to two years on: about 7 points less pain on a scale of 100, and the researchers are reasonably confident about that (Jenkins et al., Lancet Rheumatol 2025, 75 trials, 15,395 participants). Effects are enhanced by combining it with exercise therapy.
Note: NICE and the Zorginstituut both pulled back in 2026
On 29 July 2026 NICE withdrew its recommendations on psychological therapy for low back pain and on combined physical and psychological programmes. We are flagging that here rather than quietly dropping the reference, because until recently this page cited NICE as support.
The reason is in the accompanying surveillance decision: part of the evidence the recommendations rested on has since been retracted. NICE did not go back to the literature afterwards. It judged that an update would be unlikely to change practice much, so it dropped the recommendations rather than revising them.
Something similar happened in the Netherlands, for exactly the same reason. In April 2026 the Zorginstituut looked again at rehabilitation programmes that combine physical and psychological support. Two of the studies the reimbursement rested on turned out to have been retracted in 2024, over doubts about how reliable the data were. The conclusion: these programmes come out of the basic package for chronic pain in general, and stay covered until 2030 only for people for whom every ordinary treatment has failed. That too is not a verdict that the approach does not work. It is a verdict that the evidence is not solid enough to have everyone pay for it.
What this does not mean: that the treatment stopped working. NICE still recommends CBT and ACT in its guideline for chronic primary pain, and independent research still finds benefit a year or two later. What it does mean: be careful with anyone, including us, who tells you a psychological approach is “strongly recommended”. The effects are real, they last, and they are small.
Cognitive Functional Therapy (CFT)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
CFT is an integrated approach combining pain education, graded exposure to feared movements and lifestyle modification. The RESTORE trial (Kent et al., Lancet 2023) showed superior results on pain and functioning compared to usual care.
RESTORE trial results
- 492 participants with chronic low back pain
- Clearly fewer limitations in daily activities than with usual care
- Pain also decreased more than with usual care
- Effects maintained at 12 months
- More cost-effective than usual care
Pain Reprocessing Therapy (PRT)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
PRT is a relatively new treatment that teaches the brain to reinterpret pain signals. The PRT trial (Ashar et al., JAMA Psychiatry 2022) showed impressive results for chronic back pain.
PRT trial results
- 151 participants with chronic back pain (average 10 years)
- 66% pain-free or nearly pain-free after 4 weeks
- Compared to 20% in the placebo group
- Results maintained at 1-year follow-up
- fMRI showed changes in brain activity
What does a course look like?
Session 1
Intake
Mapping your pain, thoughts and behaviour patterns.
Week 1–6
Weekly sessions
Challenging unhelpful thoughts, gradually doing more.
Week 6–12
Putting it into practice
What you learn becomes routine in daily life.
After that
Lasting effect
Still measurable after 1 to 2 years, though small: about 7 points less pain.
When recommended?
- Chronic back pain (longer than 12 weeks)
- Fear of movement (kinesiophobia)
- Catastrophizing thoughts about pain
- Depression or anxiety related to pain
- Back pain without clear structural cause
- High psychosocial factors (stress, work issues, sleep problems)
Sources
- Ashar YK, et al. Effect of Pain Reprocessing Therapy vs Placebo. JAMA Psychiatry (2022)
- Kent P, et al. Cognitive functional therapy vs core exercises vs usual care. Lancet (2023)
- Jenkins HJ, et al. Long-term effectiveness of non-surgical interventions for chronic low back pain. Lancet Rheumatol (2025)
- NICE Guideline NG59: Low back pain and sciatica (psychological therapy recommendations withdrawn July 2026)
- NICE. July 2026 exceptional surveillance of NG59 (2026)
- Zorginstituut Nederland. Standpunt Interdisciplinaire medisch-specialistische revalidatie bij chronische pijn (2026)
- NICE Guideline NG193: Chronic pain in over 16s (2021)
- Qaseem A, et al. Noninvasive Treatments for Acute LBP. ACP (2017)
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