Chronic Pain & How Therapy can Help
How Can a Psychologist Help You with Chronic Pain?
“We no longer think of pain as a measure of tissue damage—it doesn’t actually work that way even in highly controlled experiments. We now think of pain as a complex and highly sophisticated protective mechanism.”
-Lorimer Moseley
Consider Peter. He is 48-years-old, a prominent attorney and member of his religious community, and a father of three recently-grown children. During his free time, he spends many hours playing golf, basketball, and flyfishing without ever experiencing anything but short-lived soreness. After his last child leaves for college, he notices a gnawing pain radiating through his lower back and legs. He can no longer get through even a half round of golf or game of basketball, let alone standing and bending long enough to fish. The pain has affected his work, distracting him as he reads and preventing him from rising to approach the stand. He visits his doctor, who orders an MRI, which comes back clean save for age-normative changes in his discs. The doctor is puzzled. Peter is frustrated, demanding answers. There has to be something wrong with his back. Aren’t there other tests the doctor can order? He considers surgery and medication, anything that will help him function. His doctor asks what else was happening in his life when the pain started, and Peter answers that he and his wife had become empty nesters. Hesitantly, Peter adds that his wife had approached him wondering if, now that the kids were gone, they might consider separation. This blindsided Peter and threw him into an emotional tailspin, but he doesn’t see what it has to do with his back. The doctor thinks for a moment then refers Peter to a pain clinic, where he strongly recommends consulting with a pain psychologist. Feeling somewhat dismissed and misunderstood, Peter accepts the referral and makes an appointment.
Patients like Peter are far from unique. Chronic pain affects 50 million people in the US every year. About 17 million Americans experience chronic pain to the extent that it substantially limits their day-to-day activities. Chronic pain demands a greater share of the total healthcare expenditure than cancer and heart disease combined. Physicians offer surgeries, injections, and medications to alleviate it, often with few or only short-lasting effects. The process can be maddening for the sufferer. And many, many people don’t realize noninvasive treatment options exist. Not all pain is amenable to biomedical interventions because not all pain is purely biomedical in origin. And even pain with a biomedical origin can maintain itself longterm via psychosocial factors. The longer the pain has persisted, in fact, the more likely it is that the factors maintaining it are psychological.
The Biopsychosocial Model
In the past 20 years, the biopsychosocial model of pain has eclipsed the biomedical model. The biopsychosocial model recognizes the many different ways through which pain develops and becomes persistent. Biology does not tell the whole story. Consider Peter again. He may well have had some minor disc bulging and degeneration. However, many people with these changes in their biology do not develop any symptoms at all. Combined with the increased stress from the threat of marital separation, his brain became more likely to recognize danger, lowering the threshold above which it is likely to generate pain. Think of pain as a warning signal generated by the brain when it detects credible evidence of danger. Our brains, long adapted for a dangerous world, do poorly at differentiating psychosocial and physical threats. As far as brains are concerned, there’s little difference between an impending divorce and an oncoming train.
Common Pain Conditions
The following concerns are commonly caused or greatly exacerbated by psychosocial factors:
- Fibromyalgia
- Persistent back pain and neck pain
- Sciatica or sciatic pain syndrome
- Headache diseases
- Gastrointestinal pain
- Whiplash
- Irritable bowel syndrome
- Postural orthostatic tachycardia (POTS)
- Insomnia
- Dizziness
- Tinnitus
- Chronic fatigue syndrome
- Functional neurological disorder (conversion disorder)
And there are many others. What binds these concerns is the influence of the nervous system on the rest of the body. This connection allows for factors such as anxiety and trauma to affect pain and physical health overall.
Acute Pain Vs. Chronic Pain
For academic and clinical purposes, chronic pain is defined as pain that persists for more than three months without significant remission. Doctors define it this way because most injuries heal within that timeframe. So, when pain lasts longer than three months, the likelihood that the pain itself has become the problem increases. This is tricky, because our intuition tells us that where there is pain, there is a problem in our bodies. However, we know this is not always the case. It is very possible to feel immense pain even when your tissues are perfectly fine, to be sore but safe. Consider the case of phantom limb pain, which can be very intense. There is no limb left to house the pain, but it doesn’t matter. Our brains have what researchers call a “virtual body,” a map of the body in space where it thinks the body should be. As such, it is very capable of generating pain in a part of the body that is no longer there. We don’t feel pain in the body itself. We feel it in our virtual body. Phantom pain, far from being a medical anomaly, is rather a striking example of how all pain works.
The opposite—feeling no pain even when our tissues are threatened—is also common. Have you ever noticed a cut or bruise without the slightest memory as to how it had happened? Or perhaps you’ve been injured more seriously and only noticed the severity of the injury after you were safe and calm. In both cases—where pain is a false alarm or where the alarm fails to go off—we see that pain is not a direct expression of our bodily state but rather our brain’s estimate of the sensations that will best protect us.
Another important distinction is that acute pain, though uncomfortable, typically serves a valuable purpose. It tells us something is wrong and guides our behavior toward healing. Chronic pain, on the other hand, often hurts without helping, making it all the more frustrating to cope with.
Psychological Factors that Contribute to Pain
The most common psychological concerns that correlate with chronic pain are depression, anxiety, Post-traumatic Stress Disorder (PTSD), pain catastrophizing, kinesiophobia (fear of movement), and perfectionism. All these conditions train the nervous system to operate in an activated state, one where the brain is more likely to interpret stimuli as dangerous. And we know that the more our brains detect danger, the higher our pain dial is likely to turn.
How Psychological Interventions Help with Pain
Psychological interventions target chronic pain symptoms in several ways. First, they address the psychological factors—depression, anxiety, PTSD—that may underlie the pain. Many people notice improvements in their pain symptoms as the grip of depression and anxiety loosens. Second, psychological interventions can help you learn how to regulate your nervous system. Chronic pain can both result from and cause overactivity in the sympathetic nervous system, creating ideal conditions for a vicious cycle to form. That is, pain tends to lead to anxiety and depression, which leads to heightened pain, which leads to heightened anxiety and depression, and so on. The result is a highway loop from hell with no clear exit ramps. Learning techniques to down-regulate your nervous system means building an exit ramp, slowly but surely. Third, current evidence has shown that simply learning about the science behind pain can help alleviate it, especially when you use that knowledge to expand your behavioral repertoire. With the right combination of knowledge and action, many people not only see improvements in their function; they see reductions in pain itself.
What Can You Do About Chronic Pain?
If you take anything from this page, we would like you to take this: the good news about chronic pain is that there are many tools you can use to alleviate and adjust to it. Evidence shows that simply learning about the nature of pain can go a long way toward reducing its impact on your life. A host of self-help resources for chronic pain, many of which are free, have recently emerged. The following list is far from exhaustive:
Apps and websites:
Curable
painTRAINER
Pathways
How Full Color Psychology Can Help
Self-guided learning, mental health apps, and online pain training programs are a great resource and may be all you need to find healing. However, they cannot offer the one-on-one support that a therapist can provide. Beyond that, if you are struggling with mental health concerns that contribute to your pain disorder, it is important to seek professional help.
Dr. Eric Ghelfi has trained in pain and health psychology. He provides therapy targeted to help you manage pain as well as for the many mental health conditions that coincide with it. Other providers at Full Color Psychology are well positioned to help with concerns such as PTSD, anxiety, depression, perfectionism, life stress, and difficulties with major transitions, which may also contribute to pain.
Because pain is medically and psychologically complex, it is important to work with your medical team throughout treatment to rule out and monitor organic causes. Many people with psychophysiological disorders see best results when they combine physical therapy and psychology. A multidisciplinary treatment team is vital, and your provider at Full Color Psychology would help you establish a team if you do not already have one.