Kronik Ağrı Tedavisinde Üçüncü Dalga Bilişsel-Davranışçı Terapiler: Anlatısal Bir Derleme

Öz

Kronik ağrı, dünya genelinde yetişkin nüfusun yaklaşık beşte birini etkileyen önemli bir halk sağlığı sorunudur. Depresyon, anksiyete bozuklukları ve madde kullanım sorunlarının yanı sıra geniş çaplı işlevsellik kayıplarıyla yakından ilişkili olması, kronik ağrıyı hem bireysel hem de toplumsal düzeyde ciddi bir yük haline getirmektedir. Bu çok boyutluluk, tedavide biyopsikososyal yaklaşımı gerekli kılmakta ve özellikle psikoterapötik müdahaleleri sürecin merkezine yerleştirmektedir. Bu çerçevede uzun süre “altın standart” kabul edilen Bilişsel-Davranışçı Terapi’nin (BDT), ağrıya bağlı psikolojik semptomları hedef alarak hastaların yaşam kalitesini artırmada etkili olduğu çok sayıda çalışmada tutarlı biçimde ortaya konmuştur. Son yirmi yılda ise “üçüncü dalga BDT” olarak adlandırılan çağdaş terapi modelleri kabul, farkındalık ve şefkat temelli müdahaleler aracılığıyla kronik ağrı yönetimine yeni bir boyut kazandırmıştır. Bunlar arasında Kabul ve Adanmışlık Terapisi ile Mindfulness Temelli Bilişsel Terapi, en güçlü kanıt tabanına sahip yaklaşımlar olarak öne çıkarken, Diyalektik Davranış Terapisi, Şefkat Odaklı Terapi ve Fonksiyonel Analitik Psikoterapi henüz erken aşama kanıtlarla desteklenen, ancak giderek artan klinik ilgi gören modeller olarak dikkat çekmektedir. Bu derlemenin amacı, söz konusu üçüncü dalga bilişsel-davranışçı terapilerin kronik ağrıya uyarlamalarını kuramsal dayanakları, klinik uygulama biçimleri ve kanıt düzeyleri çerçevesinde ele almak; böylece hem klinik uygulamalara hem de gelecekteki araştırmalara yol gösterici olacak bir sentez sunmaktır.

Anahtar Kelimeler

• bilişsel-davranışçı terapi
• kronik ağrı
• üçüncü dalga terapiler

Third Wave Cognitive-Behavioural Therapies in the Treatment of Chronic Pain: A Narrative Review

Öz

Chronic pain is a significant public health issue affecting approximately one-fifth of the adult population worldwide. Its close association with depression, anxiety, substance use problems, and widespread functional impairment makes chronic pain a serious burden at both individual and societal levels. This multidimensional nature necessitates a biopsychosocial treatment approach and, in particular, positions psychotherapeutic interventions at the center of care. In this context, Cognitive-Behavioral Therapy (CBT), long regarded as the “gold standard,”, has been consistently demonstrated across numerous studies to improve patients’ quality of life by targeting pain-related psychological symptoms. Over the past two decades, however, contemporary therapy models known as the “third wave of CBT” have added a new dimension to chronic pain management through acceptance-, mindfulness-, and compassion-based interventions. Among these, Acceptance and Commitment Therapy and Mindfulness-Based Cognitive Therapy stand out as approaches with the strongest evidence base. In contrast, Dialectical Behavior Therapy, Compassion-Focused Therapy, and Functional Analytic Psychotherapy are supported by early-stage evidence but are attracting increasing clinical interest. This review aims to examine the adaptations of third-wave cognitive-behavioral therapies to chronic pain in terms of their theoretical foundations, clinical applications, and levels of evidence, thereby providing a synthesis to guide both clinical practice and future research.

Anahtar Kelimeler

• chronic pain
• cognitive-behavioural therapy
• third wave therapies

Kaynakça

1. Aaron, R.V., Ravyts, S.G., Carnahan, N.D., Bhattiprolu, K., Harte, N., McCaulley, C.C., Vitalicia, L., Rogers, A.B., Wegener, S.T., & Dudeney, J. (2025). Prevalence of depression and anxiety among adults with chronic pain: A systematic review and meta-analysis. JAMA Network Open, 8 (3), e250268. https://doi.org/10.1001/jamanetworkopen.2025.0268
2. Adams, L.M., Turk, D.C. (2022). Chronic pain: Perspective on the second wave. W O'Donohue & A Masuda (Eds.), Behavior therapy: First, second, and third waves (s. 673-696). Springer.
3. Barrett, D., Brintz, C.E., Zaski, A.M., & Edlund, M.J. (2021). Dialectical pain management: Feasibility of a hybrid third-wave cognitive behavioral therapy approach for adults receiving opioids for chronic pain. Pain Medicine, 22 (5), 1080–1094. https://doi.org/10.1093/pm/pnaa361
4. Behvandi, N., Khayatan, F., & Golparvar, M. (2022). Comparing of compassion-based emotion focused therapy with compassion-focused treatment on quality of life of primary headache patients. Iranian Journal of Psychiatry and Clinical Psychology, 28 (2), 210-221. https://doi.org/10.32598/ijpcp.28.2.4025.1
5. Bendelin, N., Gerdle, B., & Andersson, G. (2023). Hurdles and potentials when implementing internet-delivered acceptance and commitment therapy for chronic pain: A retrospective appraisal using the quality implementation framework. Scandinavian Journal of Pain, 24 (1), 20220139. https://doi.org/10.1515/sjpain-2022-0139
6. Bindicsova, I., Hides, L.M., Brain, K., Hodson, F.J., Jackson, P., Jensen, M.P., Ehde, D.M., & Day, M.A. (2025). Internet-delivered mindfulness-based cognitive therapy (iMBCT) for chronic pain symptom management in adults: A pilot randomized controlled trial. The Journal of Pain, 32, 105429. https://doi.org/10.1016/j.jpain.2025.105429
7. Brown, A., Woodcock, C., Cocallis, K., & Bowman, A.R. (2022). Evaluation of a virtual compassionate living group for patients with chronic pain. OBM Integrative and Complementary Medicine, 7 (4): 15. https://doi.org/10.21926/obm.icm.2204050
8. Buhrman, M., Tillfors, M., Holländare, F., Lekström, E., Håkansson, A., & Boersma, K. (2023). Psychological treatment targeting acceptance and compassion in patients with chronic pain: A randomized controlled, internet-delivered, treatment trial. The Clinical Journal of Pain, 39 (12), 672–685. https://doi.org/10.1097/AJP.0000000000001157

9. Casey, M.B., Takemasa, S., O'Reilly, T., Leamy, M., Mc Kearney, E., Buckley, M., Smart, K.M., Segurado, R., Lowry, D., Flanagan, D., Gopal, H., Hearty, C., & Doody, C. (2024). Exercise combined with acceptance and commitment therapy for chronic pain: One-year follow-up from a randomized controlled trial. European Journal of Pain, 28 (6), 913–928. https://doi.org/10.1002/ejp.2229
10. Cattanach, B.K., Thorn, B.E., Ehde, D.M., Jensen, M.P., & Day, M.A. (2021). A qualitative comparison of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain. Rehabilitation Psychology, 66 (3), 317–334. https://doi.org/10.1037/rep0000344
11. Cohen, S.P., Vase, L., & Hooten, W.M. (2021). Chronic pain: An update on burden, best practices, and new advances. Lancet, 397 (10289), 2082–2097. https://doi.org/10.1016/S0140-6736(21)00393-7
12. Day, M.A. (2017). Mindfulness-based cognitive therapy for chronic pain: A clinical manual and guide. John Wiley & Sons.
13. Day, M.A., Ciol, M.A., Mendoza, M.E., Borckardt, J., Ehde, D.M., Newman, A.K., Chan, J.F., Drever, S.A., Friedly, J.L., Burns, J., Thorn, B.E., & Jensen, M.P. (2024). The effects of telehealth-delivered mindfulness meditation, cognitive therapy, and behavioral activation for chronic low back pain: A randomized clinical trial. BMC Medicine, 22 (1), 156. https://doi.org/10.1186/s12916-024-03383-2
14. Forden, G., Ronaghan, S., Williams, P., Fish, S., & Ford, C. (2024). Predictors of treatment outcome in cognitive behavioural therapy for chronic pain: A systematic review. Disability and Rehabilitation, 46 (21), 4877–4888. https://doi.org/10.1080/09638288.2023.2283113
15. Foroushani, N.S., Mohammadkhani, P., & Rasti, J. (2024). The effectiveness of mindfulness-based cognitive therapy on the symptoms of pain perception in older women. Salmand: Iranian Journal of Ageing, 19 (2), 242–257. https://doi.org/10.32598/sija.2023.3669.1
16. Gilbert, P. (2009). Developing a compassion-focused approach in cognitive behavioural therapy. G Simos (Ed.), Cognitive behaviour therapy: A guide for the practising clinician (s. 205–220). Routledge/Taylor & Francis Group.
17. Gilbert, P. (2010). Compassion focused therapy: Distinctive features. Routledge.
18. Gkintoni, E., Vassilopoulos, S.P., & Nikolaou, G. (2025). Mindfulness-based cognitive therapy in clinical practice: A systematic review of neurocognitive outcomes and applications for mental health and well-being. Journal of Clinical Medicine, 14 (5), 1703. https://doi.org/10.3390/jcm14051703
19. Gooding, H., Stedmon, J., & Crix, D. (2020). 'All these things don't take the pain away but they do help you to accept it': Making the case for compassion-focused therapy in the management of persistent pain. British Journal of Pain, 14 (1), 31–41. https://doi.org/10.1177/2049463719857099
20. Gray, C., Jones, F., Agostinis, A., & Morris, J. (2024). Experience of compassion-based practice in mindfulness for health for individuals with persistent pain. British Journal of Pain, 18 (4), 337–353. https://doi.org/10.1177/20494637241232555
21. Hayes, S.C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35 (4), 639-665. https://doi.org/10.1016/S0005-7894(04)80013-3
22. Holman, G., Kanter, J.W., Tsai, M., & Kohlenberg, R. (2017). Functional analytic psychotherapy made simple: A practical guide to therapeutic relationships. New Harbinger Publications.
23. Kim, D.J., Job, A., Gokarakonda, S., Huang, C., Chekuri, L., Carbajal, J.M., & Cáceda, R. (2022). Synergistic effect of chronic pain and nonsuicidal self-harm on pain sensitivity. European Archives of Psychiatry and Clinical Neuroscience, 272 (3), 371–380. https://doi.org/10.1007/s00406-021-01283-7
24. Kohlenberg, R.J., & Tsai, M. (1994). Functional analytic psychotherapy: A radical behavioral approach to treatment and integration. Journal of Psychotherapy Integration, 4 (3), 175–201. https://doi.org/10.1037/h0101264
25. Kohlenberg, R.J., Tsai, M., & Kanter, J.W. (2009). What is functional analytic psychotherapy? M Tsai, RJ Kohlenberg, JW Kanter, B Kohlenberg, WC Follette & GM Callaghan (Eds.), A guide to functional analytic psychotherapy: Awareness, courage, love, and behaviorism (s. 1-19). Springer. https://doi.org/10.1007/978-0-387-09787-9_1
26. Kovačević, I., Pavić, J., Filipović, B., Ozimec Vulinec, Š., Ilić, B., & Petek, D. (2024). Integrated approach to chronic pain-the role of psychosocial factors and multidisciplinary treatment: A narrative review. International Journal of Environmental Research and Public Health, 21 (9), 1135. https://doi.org/10.3390/ijerph21091135
27. Kruse, J.A., & Seng, E.K. (2023). Changes in cognitive appraisal in a randomized controlled trial of mindfulness-based cognitive therapy for patients with migraine. Headache, 63 (10), 1403–1411. https://doi.org/10.1111/head.14627
28. Kwon, C.Y., & Lee, B. (2023). Prevalence of suicidal behavior in patients with chronic pain: A systematic review and meta-analysis of observational studies. Frontiers in Psychology, 14, 1217299. https://doi.org/10.3389/fpsyg.2023.1217299
29. Lai, L., Liu, Y., McCracken, L.M., Li, Y., & Ren, Z. (2023). The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials. Behaviour Research and Therapy, 165, 104308. https://doi.org/10.1016/j.brat.2023.104308
30. Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
31. Linton S.J. (2010). Applying dialectical behavior therapy to chronic pain: A case study. Scandinavian Journal of Pain, 1 (1), 50–54. https://doi.org/10.1016/j.sjpain.2009.09.005
32. López-Bermúdez, M.Á., Ferro-García, R., Calvillo-Mazarro, M., & Valero-Aguayo, L. (2021). Importance of the therapeutic relationship: Efficacy of functional analytic psychotherapy with different problems. Clínica y Salud, 32 (3), 103–109. https://doi.org/10.5093/clysa2020a32