The Psychology and Treatment of Chronic Pain
The field of chronic pain management has rapidly changed and grown over the past several years. Specifically, the growing concerns about and resistance toward using opioids to manage chronic and severe pain have shaped the medical field in numerous ways. In fact, psychiatric treatment, including psychoeducation and therapy, are now recognized as first-line treatments for chronic low back pain (Subramanian, 2021). In my own practice, I regularly receive referrals for individuals experiencing a myriad of chronic pain.
As a provider specializing in the psychological management of chronic pain, I am often asked why my patient’s medical providers referred them for psychological treatment. Unfortunately, medical providers often do not have the language and/or training to help their patients understand why a psychologist could be helpful in managing their chronic physical pain. As a result, patients are often left feeling that their medical providers believe that their pain is “all in their head.”
To understand why therapy is often recommended to patients experiencing chronic pain, it is helpful to turn to research to gain a better understanding of chronic pain in general.
Zirriny and Boyce (2019) note that once pain occurs for 6 months or longer, it is classified as chronic in nature. Current research indicates that approximately 20% of the U.S. population suffers from chronic pain; costing more than $600 billion to manage (Ashar et al., 2022). In fact, the APA (2013) states that chronic pain affects more Americans than diabetes, heart disease, and cancer combined. Notably, lower back pain is the most common form of chronic pain experienced in the U.S.
Studies have indicated that physical pain, depression, and anxiety move through similar pathways within the nervous system. Specifically, the limbic area of the brain, which is partially responsible for emotional functioning, shares many of the same messengers as the areas of the brain responsible for processing physical pain (Zirriny & Boyce, 2019). Additionally, Ashar et al. (2022) note that “as pain becomes chronic, it is increasingly associated with activity in the affective and motivational systems tied to avoidance.”
Generally, I tell my patients that chronic pain and mental health tend to create a cyclic pattern. As chronic pain increases, so does emotional distress; which, in turn, causes the pain to increase even more. Vadivelu et al. (2017) note that approximately 30-45% of patients with chronic pain also experience depression.
I often encourage my own patients to consider that chronic pain often robs them of the coping strategies and activities that helped to keep depression and anxiety at bay. For example, individuals with chronic pain often find themselves unable to engage in physical activity (i.e. running, walking, weight lifting, etc.), which is one of the best-known behavioral strategies to decrease emotional distress. It is, therefore, not at all surprising that individuals suffering from chronic pain also experience higher rates of mental health concerns.
The APA (2013) states that chronic pain often leaves individuals feeling angry, sad, anxious, and hopeless. Without addressing psychological factors associated with chronic pain, patients will likely experience increased difficulties managing their chronic pain independently. A therapist can assist patients in exploring factors that affect their pain, including their thoughts and emotions associated with the pain (APA, 2013).
Cognitive Behavior Therapy (CBT) is often used to assist patients in identifying and addressing catastrophizing thought patterns, fears related to pain, and the trauma (i.e. a car accident, the experience of abuse, physical harm, etc.) that may have created the pain in the first place (Zerriny & Boyce, 2019). Additionally, CBT can help patients learn how to reframe their thoughts to positively impact their behaviors and emotions (Subramanian, 2021).
Additionally, it is common for individuals experiencing chronic pain to also experience muscle tension and muscle spasms, which ultimately increase physical pain. Individual therapy can assist patients in learning breathing strategies, muscle relaxation techniques, and other relaxation strategies to assist in reducing the experience of physical pain.
As a final note, clinicians trained in Acceptance Commitment Therapy (ACT) work with patients to learn how to accept their pain so that they can then find a life they find worthwhile (Subramanian, 2021). More specifically, ACT works with patients to combine CBT-based strategies and mindfulness to learn how to accept their emotions and circumstances (Subramanian, 2021). Studies have found that approximately 48% of patients participating in ACT-based therapy demonstrated less disability resulting from pain. Further, these results remained at 3-month follow-ups (Vowles et al., 2014).
On the surface, it often seems that therapy will not be useful in managing chronic pain. However, as discussed earlier, chronic pain and mental health are intricately related, and ignoring one’s mental health often results in increased physical pain. Patients who work with therapists to address chronic pain are able to learn cognitive, relaxation, and coping strategies to reduce their physical pain and improve their quality of life.
About the Author
Dr. Montes is a licensed clinical psychologist and co-owner of Cognitive Behavior Therapy Center in Chesapeake, VA.
American Psychological Association. (2013, December 15). Managing chronic pain: How psychologists can help with pain management. Https://www.apa.org/topics/pain/management
Ashar, Y., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T., Kragel, P., Dimidjian, S., Lumley, M., & Wager, T. (2022, January 1). Effect of pain reprocessing therapy vs Placebo and usual care for patients with chronic back pain. JAMA Psychiatry. Retrieved March 28, 2023, from https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694?guestAccessKey=3e677261-f26b-4244-858c-8d319ea5b2f4&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=092921
Subramanian, S. (2021, November 22). How psychologists can help treat chronic pain (published 2021). The New York Times. Retrieved March 27, 2023, from http://www.nytimes.com/2021/11/09/well/mind/psychologists-chronic-pain-therapy.html
Sussex Publishers. (2022, March 1). Acceptance and commitment therapy. Psychology Today. Retrieved March 27, 2023, from http://www.psychologytoday.com/us/therapy-types/acceptance-and-commitment-therapy
Vowles, K. E., Fink, B. C., & Cohen, L. L. (2014, April). Acceptance and Commitment Therapy for Chronic Pain: A Diary Study of treatment process in relation to reliable change in disability. Journal of contextual behavioral science. Retrieved March 28, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5096642/
Vadivelu, N., Kai, A. M., Kodumudi, G., Babayan, K., Fontes, M., & Burg, M. M. (2017). Pain and psychology-a reciprocal relationship. The Ochsner journal. Retrieved March 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5472077/#:~:text=Conclusion%3A,the%20areas%20affected%20by%20depression.
Zerriny, S., & Boyce, D. (2019, August 14). I'm in pain, so why is my doctor suggesting a psychologist? Harvard Health. Retrieved March 27, 2023, from http://www.health.harvard.edu/blog/im-in-pain-so-why-is-my-doctor-suggesting-a-psychologist-2019081417450