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Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain.

TO THE EDITOR: We appreciate Thorn and colleagues' (1) randomized controlled trial comparing literacy-adapted, simplified group cognitive behavioral therapy (CBT) with group pain education and usual care. As the authors note, chronic pain is a common problem that disproportionately affects groups with low socioeconomic status (SES); finding an effective intervention for these persons is thus essential (1, 2). Behavioral economics is a useful lens through which to examine the treatment of chronic pain in populations with low SES. Persons who face scarcity (including those struggling with poverty) are mentally taxed and may have reduced cognitive capacity, or “bandwidth” (3). Although cognitive capacity is traditionally believed to be fixed, research has shown that multiple factors can reduce a person's bandwidth, including poverty (4). A person who struggles with poverty will have decreased mental resources to devote to issues aside from finances and basic needs (4) and may not have the available cognitive capacity to focus on therapy or education if they are struggling to make ends meet. For example, we have noted that patients with low SES and limited literacy struggle with understanding basic tenets of CBT, such as differentiating among thoughts, feelings, and actions. This concept of bandwidth is also important because the amount required to attend 6 or more CBT sessions, defined as adequate dosage in Thorn and colleagues' study, is considerable for a vulnerable population. We admire the 75% uptake rate of Thorn and colleagues' CBT intervention in this study. Here we highlight steps that might economize bandwidth and promote the uptake of CBT interventions in patients with low SES. Programs can be simplified to reduce the cognitive burden on available bandwidth while still maintaining the benefits of an intervention (3). In Thorn and colleagues' study, the investigators reduced required bandwidth for participants by using a literacy-adapted CBT program. The LAMP (Learning About My Pain) modules include content that has anecdotally resonated during individual CBT sessions with our patients with low SES, including the connection between stress and pain and the “pain and fear cycle.” In addition, we suggest that interventions take place at the beginning of the month after persons receive paychecks to avoid the decreased bandwidth that can occur toward the end of the month as budgets are stretched (4). Overall, we believe that this low-literacy adaptation of CBT is an important step forward in treating chronic pain in a disproportionately affected population.