Nov. 9, 2021
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How Psychologists Can Help Treat Chronic Pain
Over the past two decades, as the opioid crisis has shaken the public’s view of painkillers and pharmaceutical companies have come under fire for their marketing practices, many patients are looking for alternatives. One of the leading contenders has become treating pain with talk therapy.
Psychologists, therapists and social workers have quietly become a crucial part of pain treatment programs, proving to be as effective or more so than medication. In 2018, the medical journal The Lancet went so far as to recommend education and psychological treatment as first-line interventions for chronic low back pain, before pharmacological treatment.
A spokesman for the American Psychological Association said they have only recently started tracking pain psychology and in 2021 found that nearly 40 percent of its members report their patients frequently have chronic pain. The organization is currently drafting guidelines for chronic pain treatment, a sign, according to Lynn Bufka, a Maryland psychologist and a senior director at the A.P.A., that it’s an important and growing field with science-based solutions.
Still, finding the right pain counseling can take a bit of effort on the part of the patient. Here are a few things to consider before you get started.
What does a pain psychologist do?
Many pain psychologists treat chronic pain with cognitive behavior therapy, or C.B.T., which focuses on reframing thoughts to positively affect behavior and emotions, or mindfulness, which involves learning to become conscious of feelings without reacting to them. Acceptance and commitment therapy combines mindfulness and C.B.T. to help patients accept their emotions and respond to them.
Another method psychologists use to treat pain is biofeedback, which monitors a person’s muscle tension, heart rate, brain activity or other functions in real time to make patients aware of their stress and learn to control it. Lastly, some clinicians use hypnosis, which can be effective at managing pain for some people.
What unifies all these treatments is a focus on teaching patients how they can use their minds to manage their pain.
How do you find a pain psychologist?
Finding a pain psychologist can be tough. Large medical centers and boutique practices are more likely to have comprehensive pain treatment but also tend to be in urban areas. People in rural areas or those who can’t afford the services get left out, said Rachel Aaron, an assistant professor of physical medicine and rehabilitation at Johns Hopkins Medicine. But even in urban areas, not all large medical networks have pain services.
“It’s definitely a challenge to get from the initial pain diagnosis to psychological care no matter what system you’re in,” said Dr. Aaron.
There are no specific certifications for pain management therapists, said Eric Garland, director of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah, nor does the American Psychological Association track their numbers. But most experts agree there is a shortage of pain-focused psychologists, just as with other mental health professionals.
If you are interested in trying a pain therapist, Dr. Aaron said, the first stop is your primary care doctor. Some insurance plans cover pain psychology, but others do not. It’s important to talk to a mental health provider first about how to get treatment covered.
After that, look for specialized pain clinics by calling hospitals in your area or use the Find a Therapist function on the Psychology Today website. Search for a provider who either treats your specific condition, be it fibromyalgia or migraines, or who treats chronic pain more broadly, a specialty often referred to as behavioral medicine or health psychology. There are also online programs that are evidence-based and freely available; Dr. Aaron recommends PainTRAINER and Pain Course.
Some experts recommend working with licensed professionals with doctorates or master’s degrees in psychology or clinical social work with additional training in chronic pain, and to interview them about their training and approach before getting started.
“If they can’t give a clear answer on their approach or how they would treat your specific pain issue, they probably don’t have good training,” Dr. Garland said.
Most importantly, you should feel comfortable enough to open up with them.
What should you expect?
Most pain therapy programs start with six to eight weekly sessions, said Fadel Zeidan, an associate professor of anesthesiology and executive director at the Center for Mindfulness at the University of California, San Diego. Often the first session is an evaluation to learn about the pain problem and the emotional issues it may be causing. You might then learn mindfulness techniques to separate the physical and emotional aspects of pain, train yourself to reframe negative thought patterns or practice paying more attention to pleasant sensations.
One recent paper in JAMA Psychiatry found that two-thirds of chronic back pain patients who underwent four weeks of psychological treatment were pain-free, or nearly so, afterward. However, most studies show a more modest effect — about one-third of participants see a significant decrease in pain.
To put this in perspective, this is about the same as opioids’ effect on chronic pain, but those benefits diminish over time (and they come with risks). The effectiveness of psychological pain management skills, on the other hand, can increase with practice.
Dr. Zeidan recommended trying different methods at once — individualized therapy, pain management courses and group therapy. “We don’t actually know what the silver bullet is because there likely isn’t one to cure pain. So testing, validating and optimizing multiple approaches is a critical step.”
What if you can’t see a psychologist in person?
The definitions insurance companies use for chronic pain are rapidly changing — with pain being increasingly seen as its own disease — but for now it’s hard to get a trip to a pain psychologist covered. That can put one-on-one treatment out of reach for many.
“We do not have enough trained psychologists to address all of the need,” said Beth Darnall, the director of the Stanford Pain Relief Innovations Lab. “We really have to look beyond what we are doing now.”
Dr. Darnall said that technology could provide new alternatives, since many of the psychological tools shown to diminish pain can be learned and shared with minimal training. She has created a program, based on C.B.T. and other models, called Empowered Relief, which is affordable and can be done from your own home.
Patients can sign up, often for free, for a single two-hour online class delivered by her or one of 300 instructors, all health care professionals, who offer simple skills to calm the nervous system, reframe pain and change how your brain processes it. It’s been integrated into the Cleveland Clinic for chronic pain and spine surgery patients, as well as several insurance companies. In one trial, a single class was comparable to eight sessions of C.B.T. She’s also currently working on an app and even virtual reality platforms.
“You can live on a ranch in Idaho and get quality access to evidence-driven pain care,” she said.
Dr. Darnall stressed that psychological counseling is just one component of a treatment program for chronic pain, which can also include medication or lifestyle changes.
“It’s not psychological treatments or medication,” Dr. Darnall said. “It’s a menu, and patients might land on two or three different options that offer a good formula for them.”
August 14, 2019
Dr. David Boyce is board-certified in general anesthesiology and pain medicine. After graduating from Tufts University School of Medicine, he completed his residency and a pain medicine fellowship at Brigham and Women’s Hospital in Boston. He … See Full Bio
Salim Zerriny, MD is a 3rd-year resident, currently training at Brigham and Women’s Hospital Anesthesiology Program. He has a special interest in pain and healthcare innovation. See Full Bio
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Most people consider chronic pain—such as pain that lasts for months or years from a bad back or arthritis—a medical condition that should be treated exclusively by a physician or physical therapist. Although this view of chronic pain is common, it is often incorrect—and has resulted in much unintended harm, particularly in recent years. In this post, we’ll learn how a simple medical model for chronic pain frequently produces disappointing treatment results and examine an alternative model for chronic pain based on the best available pain research that reduces harms while improving results.
Source: Steve Buissinne from Pixabay
How people think about chronic pain is important for two reasons. One reason is that chronic pain is one of the most common types of health problems among U.S. adults. Statistics from the Center for Disease Control, for example, indicate that chronic pain affects 1 in 5 (20 percent) of adults. This translates to more than 50 million Americans! Whatever becomes the consensus thinking about chronic pain, therefore, will influence a lot of people.
The second reason is that when people with chronic pain see their condition only as a medical problem, they run the risk of over-relying on medical treatments such as pain medicines and surgeries. Clearly, some patients with chronic pain obtain excellent results with medical treatments alone; however, many other patients either obtain limited improvements or even suffer harms such as surgical complications or addictions to pain medicines. The more a patient relies on medical approaches as their primary treatment for chronic pain symptoms, the higher their risk of experiencing these negative outcomes.
Based on more than a half-century of pain research, we now know that it is more accurate to think of chronic pain as being both a medical condition and a psychological condition. The psychological part of chronic pain refers to the degree of negative social, emotional, and quality of life effects experienced by a patient. In the same way that patients with chronic pain differ greatly in regards to how much the medical side of their condition affects them—one patient with chronic back pain may continue to work and maintain most of their social activities in modified form, for example, whereas another patient with chronic back pain may be unemployed and socially isolated—so too do patients vary in the degree to which they struggle with the psychosocial side of chronic pain. Research shows, for instance, that 33 to 50 percent of patients with chronic pain report clinically elevated levels of depression or anxiety.
Source: Thomas Rutledge
To appreciate the psychology of chronic pain, it is useful to refer to a classic psychological theory called Maslow’s hierarchy of needs. Shown in the left figure, psychologist Abraham Maslow believed that human motivation could be understood in terms of innate drives to fulfill physical, social, intellectual, emotional, and spiritual needs. He also believed that these needs could be ordered from basic needs shared across animal life—such as safety—to the highest-level, human-only need he called self-actualization. In Maslow’s model, psychological pain and emotional suffering resulted when people were unable to find ways to fulfill their human needs or when they become trapped in a low-level need and unable to grow (e.g., financial stress causing a person to struggle to meet basic housing and security needs or a divorce producing depression by disrupting important social and emotional needs).
Chronic pain is a rare condition with the ability to disrupt ALL levels of Maslow’s hierarchy. Beyond the unpleasant experience of pain itself, consider some of the ways that chronic pain affects our human needs:
- Pain limits our ability to maintain our family roles as breadwinners, parents, and spouses. Guilt is a common experience among patients with chronic pain when they feel inadequate as parents or romantic partners.
- Pain increases our dependence on others. Over time, many patients with chronic pain come to feel like burdens.
- Pain creates uncertainty about the future, upsetting financial stability and future goals. Anxiety and fear are the most common emotional responses to chronic pain.
- Pain harms relationships with family, friends, and work. Patients with chronic pain frequently become isolated and disconnected from others.
- Pain often steals sources of happiness, contribution, and achievement as a patient’s ability to engage in hobbies, work, and recreational activities is reduced.
The result is that chronic pain adds many sources of stress—while simultaneously subtracting many of our sources of reward and meaning.
Because chronic pain includes a medical side and a psychological side, many patients with chronic pain benefit from including a pain psychologist as part of their treatment program. Patients often react to a pain psychology recommendation as a threat, believing that pain psychology is for patients whose pain is “in their heads.” However, this is simply not true. Pain psychology treatments are potentially useful for every patient with chronic pain. This is because pain psychology aims to help each patient address the ways in which their pain condition is interfering with their ability to fulfill their human needs, using many different treatment approaches to restore relationships and improve function, meaning, contribution, and sources of personal growth.
LinkedIn Image Credit: Roman Samborskyi/Shutterstock
