Psychological therapies for the management of chronic pain

Psychological therapies for the management of chronic pain – from PubMed

Pain is a complex stressor that presents a significant challenge to most aspects of functioning and contributes to substantial physical, psychological, occupational, and financial cost, particularly in its chronic form.

As medical intervention frequently cannot resolve pain completely, there is a need for management approaches to chronic pain, including psychological intervention.

Psychotherapy for chronic pain primarily targets improvements in physical, emotional, social, and occupational functioning rather than focusing on resolution of pain itself. However, psychological therapies for chronic pain differ in their scope, duration, and goals, and thus show distinct patterns of treatment efficacy.

These therapies fall into four categories:

  1. operant-behavioral therapy,
  2. cognitive-behavioral therapy,
  3. mindfulness-based therapy, and
  4. acceptance and commitment therapy.

The current article explores the theoretical distinctiveness, therapeutic targets, and effectiveness of these approaches as well as mechanisms and individual differences that factor into treatment response and pain-related dysfunction and distress. Implications for future research, dissemination of treatment, and the integration of psychological principles with other treatment modalities are also discussed.

Pain is an essential biological function that signals disturbance or damage in the body, prevents further harm through overuse of the afflicted area, and promotes physiological homeostasis. Whether through abnormal healing, additional bodily damage, or failed medical intervention, pain may become chronic. Chronic pain no longer signals damage to the body and is instead a detriment to the physical and psychological well-being of the sufferer

Recurrent pain may contribute to development of maladaptive cognitions and behavior that worsen daily functioning, increase psychiatric distress, or prolong the experience of pain

the relationship between depression and pain is likely bidirectional, as the presence of a major depressive disorder has been identified as a key risk factor in the transition from acute pain to chronic pain

Additionally, individuals with pain may suffer from significant anxiety and depressive symptomatology that does not reach the severity of a clinical diagnosis.

Given the negative psychological consequences of chronic pain, it is worthwhile to consider three psychological mechanisms related to pain-related distress that have proven to be suitable targets for intervention: pain catastrophizing, fear of pain, and pain acceptance.

Pain catastrophizing is defined as a negative cognitive and affective mental set related to expected or actual pain experience. Pain catastrophizing is characterized by magnification of the negative effects of pain, rumination about pain, and feelings of helplessness in coping with pain.

As stated earlier in the article, pain is biologically designed to override our everyday thoughts, so “rumination” would normally be the correct response, and “feelings of helplessness” are very real when you can’t get pain control. Not being able to get pain medication is a very real “helplessness”, not just a feeling.

Pain-related fear is another psychological mechanism that has significant implications for physical and psychological functioning in chronic pain.

When a patient’s access to pain medication is being threatened, “fear” is a normal response when contemplating a life of unending chronic pain. I’m not afraid of my pain as much as I’m afraid of being denied the medication to keep it under control.

Recently, there has been increased attention to the psychological flexibility model, which extends the fear-avoidance model of chronic pain and proposes to improve treatment outcomes through fostering of accepting attitudes towards pain.

Psychological flexibility has been defined as an ability to engage in the present moment in a way that allows the individual to either maintain or adjust his or her behavior in the way that is most consistent with internally held goals and values;

pain acceptance is defined as a process of nonjudgmentally acknowledging pain, stopping maladaptive attempts to control pain, and learning to live a richer life in spite of pain.

Pain acceptance influences emotional functioning through two distinct mechanisms:

  1. a willingness to experience pain, which buffers against negative emotional reactions to pain, and
  2. continued engagement in valued activities despite the presence of pain, which bolsters positive emotions.

Psychological intervention as an approach to pain management

Operant behavioral approaches

According to this theory, a behavioral drive to avoid pain leads individuals to avoid behaviors that are painful but maintain their physical and emotional health; this avoidance contributes to the development and maintenance of pain chronicity, deconditioning, and depression.

Operant therapy for chronic pain utilizes reinforcement and punishment contingencies to reduce pain-related behaviors and foster more adaptive behaviors,

Punishing for pain behaviors is like parents smacking their children for crying in pain which the parent regards as inconsequential: “I’ll give you something to cry about”. Remember how demeaned and helpless that made you feel? Are these the same people pushing Operant Behavior retraining? This is not teaching or even training – it’s purely impersonal conditioning on a biologic basis, like Pavlov’s dogs salivating at the sound of a dinner bell.

A recent application of learning theory to chronic pain involves in vivo exposure treatment for pain-related fear, which focuses on decreasing the perceived harmfulness of physical activity.

Learning theory posits that the aversive signal of pain may be passed to neutral stimuli (like physical movement behaviors), which contributes to avoidant behavior.

Consistent with exposure treatments for phobias and other anxiety disorders, in vivo exposure treatment for fear of pain involves development of a personalized, graded hierarchy of activities that elicit a fearful response, psychoeducation related to pain, fear, and behavior, and ultimately slow and systematic exposure to activities related to the individual’s fear hierarchy.

Ignored here are all the cases of invisible pain that could be the sign of a physical malfunction, like EDS.  In such cases, pain indicates that damage is occurring.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) adopts a biopsychosocial approach to the treatment of chronic pain by targeting maladaptive behavioral and cognitive responses to pain and social and environmental contingencies that modify reactions to pain

According to recent meta-analytic studies,45 CBT for pain demonstrates small-to-medium effect sizes in a variety of domains and shows effects on pain and functioning comparable to standard medical care for pain.3

related changes in helplessness and catastrophizing are uniquely predictive of later changes in pain intensity and pain-related interference in daily functioning

The intractable nature of chronic pain may make adaptation difficult as attempts to control pain may prove ineffectual, ultimately contributing to greater psychological distress Recent efforts have thus expanded the cognitive-behavioral model of pain intervention to address these issues, which has yielded two newer treatment modalities:

  1. mindfulness-based stress reduction (MBSR) and
  2. acceptance and commitment therapy (ACT).

Unlike CBT, these approaches focus on fostering acceptance of chronic pain rather than emphasizing strategies for controlling pain, thereby improving emotional well-being and greater engagement in nonpain-related pursuits. Though these interventions both target acceptance of pain, they differ in their therapeutic implementation and approach to meditation and daily practice.

some pain disorders (such as fibromyalgia) have shown comparatively poorer treatment response to CBT than other pain disorders

Perhaps this is because the pain of fibromyalgia has been proven to have a physical, functional origin, meaning it has become medically “real”.

Psychological therapies for pain are presumed to be at low risk for adverse effects to the recipient; as a result, there is a dearth of empirical evidence regarding the risks of psychological interventions. Some have suggested that patients who enter psychological treatment face risks of incorrect psychological diagnosis, psychological dependence, undermining of a patient’s ability to make their own decisions, or manipulation by the therapist to achieve nontherapeutic goals.

Factors affecting the outcomes of psychological intervention

Practitioners should be cautioned against the assumption of homogeneity among patients with pain disorders, as a variety of factors may predict treatment response.

Turk proposed that individuals coping with comparable levels of pain show distinct patterns of response that could be clustered into recognizable subclasses:

  1. “dysfunctional” patients, who report high levels of pain-related interference and distress;
  2. “interpersonally distressed” patients, who report lacking the support of loved ones in coping with their pain; and
  3. “adaptive copers,” who report notably higher levels of function and perceived social support and lower levels of pain-related dysfunction.

Additionally, there may be demographic, psychological, and medical differences among patients that are relevant to treatment response, including the etiology of pain conditions, socioeconomic status, and cultural and ethnic background


Psychotherapy constitutes a valuable modality for addressing the behavioral, cognitive, emotional, and social factors that both result from and contribute to pain-related dysfunction and distress through enhancement of self-management strategies.

However, there’s a thin line between sending pain patients to a therapist to help them cope with daily pain, and sending them to be talked into stopping their pain medication, as was done with me.

My neurologist, after several suggested treatments didn’t help me, referred me to a therapist.  I believed it was to help me deal with the depression that comes with chronic pain.

Only later did I discover that she had sent me to an “addiction counselor” because she had decided my pain didn’t have a physical cause.  Too many doctors decide that pain is purely psychological when all the treatments they personally know of and believe in fail.  

If they cannot figure out what’s causing our pain, their reaction is often not further investigation or even sympathy, but rather the conclusion that there is no physical cause. Yet, with increasingly advanced technology and investigative techniques, scientists are discovering the mechanisms behind various pains whose cause was unknown even a few decades ago.

So, when a patient presents with pain without a known cause, it could very well be due to an as yet undiscovered physiologic process. For a doctor to assume that “if I can’t find a cause, there must not be one” seems unprofessional and arrogant.

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