Psychotherapy for Chronic Pain

Chronic pain treatment: Psychotherapy, not opioids, has been proven to work – Vox – By Brian Resnick @B_resnick brian@vox.com – Aug 16, 2018

When pain settled into Blair Golson’s hands, it didn’t let go.

What started off as light throbbing in one wrist 10 years ago quickly engulfed the other. The discomfort then spread, producing a pain much “like slapping your hands against a concrete wall,” he says. He was constantly stretching them, constantly shaking them, while looking for hot or cold surfaces to lay them on for relief.

But worse was the deep sense of catastrophe that accompanied the pain. Working in tech-related startups, he depended on his hands to type.  

“Every time the pain got bad, I would think some variation of, ‘Oh no, I’m never going to be able to use computers again; I’m not going to be able to hold down a job; I’m not going to be able to earn a living; and I’m going to be in excruciating pain the rest of my life,’” he says.

Like many patients with chronic pain, Golson never got a concrete diagnosis.

For a decade, the 38-year-old Californian went from doctor to doctor,trying all the standard treatments: opioids, hand splints, cortisone injections, epidural injections, exercises, even elective surgery.

Golson’s pain was not caused by anything physically wrong with him. But it wasn’t imagined. It was real.

That ultimately took a pain psychologist, a therapist who specializes in pain — not a physicianto treat the true source: his fearful thoughts.

How could his fearful thoughts lead to the pain when it’s the pain that led to his fearful thoughts?

Realizing that psychological therapy could help “was one of the most profoundly surprising experiences of my life,” Golson says. No doctor he ever saw “even hinted my pain might be psychogenic,” meaning pain that’s psychological in origin.

Big pharma’s aggressive marketing of pills and the minimal training doctors get in pain medicine mean that for too long, the go-to treatment for many forms of chronic pain has been opioids. Yet opioids have proven to be not only largely ineffective for treating most chronic pain [?] but also highly addictive and risky.

Cognitive behavioral therapy, meanwhile, shows meaningful benefits on chronic pain — both for psychogenic pain, and for pain with a physical cause — according to systematic reviews of the research. There’s also promising research around mindfulness-based stress reduction and therapies inspired by it.

Yet pain psychologists are hard to find and hard to pay for, and most patients don’t even know they exist.

While I don’t believe our mental state “causes” our pain, I believe we can all use some help in dealing with its impact on our lives. I feel I desperately need a pain psychologist to help me figure out how to find meaning in my limited life but, as the article said, they are hard to find and hard to pay for.

“At the moment, [these therapies] tend to be seen as a route of no hope for the hopeless, for people who have gone through everything else,” says Amanda Williams, a psychological researcher who conducted one of the reviews of studies on the effectiveness of psychological therapy for pain.

The question, then, is how we shift our understanding of pain so that psychology is the opposite of a last resort.

Pain can be manufactured in your head and in your body

Doctors have long known that pain can exist in the absence of any physical harm. 

There’s a famous case study that describes a construction worker who came into the emergency room with a 6-inch nail in his boot. It was so painful, the report says, that the patient had to be sedated with powerful opioids. When the shoe was removed, it turned out the nail had passed clean between the toes. There was no injury.

Likewise, doctors have known that pain can be suppressed without any real medical intervention.

This may be the case in emergency situations, but I’ve never heard of pain that continues day after day being “cured” without medical intervention.

The placebo effect can account for much of a medicine’s pain-relieving power.

How I wish this were true of me!

For many years, I tried many highly recommended non-opioid pain-relieving treatments that I fully expected to ease my pain, only to face eventual disappointment.

If the placebo effect worked for more than a few days it might be effective, but I don’t believe a placebo has any enduring effect. I haven’t seen any studies that prove a lasting placebo effect; research studies are only short-term.

Pain, explained

How pain works is incredibly complicated, involving nerve endings in the body, many regions of the brain, and an additional nerve pathway from the brain back down to the body.

Plus, there are various inflammatory chemicals in the body that can enhance or diminish the experience of pain.

A malfunction at any juncture of these pain pathways can lead to chronic pain. This “breaking” is sometimes referred to as central sensitization, and it leads people to misinterpret normal sensations coming from their nerves as pain.

Chronic pain may start off as an acute injury and then never go away. It could also be the result of nerve problems, or degenerative diseases like arthritis.

Some people might be more susceptible to acute pain turning into chronic pain due in part to genetics. And there’s some evidence that differences in brain structure can predict who goes on to develop chronic pain and who does not.

Physical problems in the body don’t always create pain in our minds, for reasons scientists don’t quite understand. Many people with herniated spinal discs (a common explanation for lower back pain) often have no pain at all.

Overall, the takeaway is that “pain isn’t just something that happens to us,” says Beth Darnall, a professor of anesthesiology at Stanford University. “We are participating with pain by how much attention we give to it, by the contents of our thoughts, and our appraisal. How awful and negative is it? How helpless and hopeless do you feel about it? Do you feel [like] a victim; do you feel at the mercy of your pain?

The implication is that we shouldn’t feel that way, yet that is the “real” reality we live with.

It seems that people without pain believe they can know “how things are” with us when they actually have no idea. I had no idea either until I had chronic pain myself.

Psychotherapy helps you tell a new story about pain

Golson had been catastrophizing his pain, thinking of the worst possible outcomes, like losing his job or having to largely start over in life. A similar thing happens to people who suffer from anxiety: Feelings get magnified in a loop of negative rumination.

Research has shown that catastrophizing is associated with worse pain outcomes: more intense pain, and a greater likelihood to develop chronic pain. It’s also associated with higher levels of fatigue.

Neuroimaging studies suggest that if you engage in catastrophizing thoughts, it amplifies pain processing — “so you’re unwittingly pouring gasoline on the fire,” Darnall says.

But as a chronic pain patient who bounces from specialist to specialist seeking a diagnosis, it’s hard not to catastrophize.

“I think one of the most terrifying things is not knowing [what’s wrong],” says Dania Palanker, a health insurance expert at Georgetown University who suffered for years with debilitating lower back and joint pain. She went from doctor to doctor before finally receiving a diagnosis of small fiber neuropathy (which is damage to certain nerve fibers). “It’s a terrifying feeling. You don’t know — is it just going to get worse and worse? Am I going to be completely incapacitated at some point?”

In addition to her medication, she says mindfulness therapy helped her feel less threatened by her pain. “I know that it’s just that my nerves are broken,” Palanker says, which helps her disregard the pain at times.

Golson had received a therapy called pain reprocessing therapy, which is currently being tested with a clinical trial. It’s a psychological therapy that uses a technique called somatic tracking, where patients just take time to notice the feelings and sensations going on in their body while assessing those sensations and determining whether or not they should fear them. (This exercise is also common in mindfulness meditation.)

The goal of the therapy is to get the patients to reinterpret the sensations they feel as non-dangerous.

I somehow always knew that my pain didn’t mean anything was “broken”, perhaps because I had so many different pains all the time. I felt my pain was a challenge to be overcome and fearlessly threw myself into marathon races to prove I couldn’t be held back.

And when you are able to attend to a sensation without fear, assuming the pain is nonstructural in nature, the pain will decrease,” Gordon says

I tried to mentally overpower my pain for 12 years before I finally couldn’t push through it anymore and sought medical help.

You might be thinking: Isn’t this all a placebo response? Well, maybe. But don’t dismiss placebos’ healing power. Even powerful painkillers like morphine are much less effective when people don’t know they’ve taken them.

The clinical trial is still running, so the results are not yet clear. But the researchers have thrown in a few interesting wrinkles.

  1. A third of the patients (who all suffer from chronic back pain) will receive pain reprocessing therapy,
  2. another third will get no therapy at all, and
  3. a third group will actually get an open-label placebo injection.

That is, they’ll get an injection they’re told is just a placebo, which, perplexingly, has been shown in some studies to relieve some forms of chronic pain.

All the patients in the clinical trial will undergo fMRI brain scans to see if there are changes in the regions best associated with the stories we tell about ourselves. “

A key goal and outcome of many psychotherapies is helping the client tell a different story about themselves,” says Yoni Ashar, a University of Colorado Boulder neuroscience researcher and collaborator on the trial.

“The empirical literature clearly links ‘storytelling’ and placebo brain regions, and it seems very likely that the process of psychotherapy heavily recruits these regions as well.”

It could be that psychological therapy is kind of like a strong placebo, or that placebo is a weak form of therapy.

Now, that’s an interesting idea. It seems like a watered down version of the ridiculous saying “If you can dream/believe it, you can do it”.

Any patient who lives with serious pain can tell you this is absolute nonsense. How often do we dream/imagine being without pain? How often *are* we without pain?

The best evidence base is for cognitive behavioral therapy

Psychological treatments are no cure-all for chronic pain.

This disclaimer should be closer to the beginning of this article, which is insinuating that virtually all chronic pain is psychologically maintained.

The most common psychological treatment for pain, and the most well-studied, is cognitive behavioral therapy, or CBT.

Overall, it’s one of the most rigorously tested and effective tools psychology has to offer. More typically, it’s used to treat anxiety, phobias, and mood disorders like depression. But it can also help some people manage their pain.

Like the somatic tracking exercises described above, the goal of CBT is to come to a new understanding about pain. That it isn’t something that’s physically harmful and that certain thoughts and behaviors can make pain worse.

But what about those of us who are not afraid of our pain, who know we aren’t causing damage even when exercise is painful?

What about those of us who ignored the pain and “powered through it” as suggested, only to be diagnosed much later with a physical disorder (EDS) which we worsened significantly by ignoring the pain?

CBT “helps people change ways of processing their beliefs and their experiences when they are overly negative,” she says.

No amount of CBT can repair the defective connective tissue I was born with, and it cannot prevent further painful damage as my condition deteriorates.

It also targets behaviors, encouraging people to exercise (a useful tool in reducing many forms of pain) and change problematic manners of movement.

It doesn’t work perfectly for everyone.

Well, thank you for finally saying that.

Justin Hardcastle is a 27-year-old in the Pacific Northwest who receives disability benefits for intense migraines. For him, CBT didn’t relieve his symptoms.

But at least, he says, it was nice “having some space to vent to someone who is trained to respond to that venting.” He felt “a lot less guilty” complaining about things in therapy than to the people closest to him.

So, the benefits patients get from CBT can actually be just from being able to talk freely about their pain with another person. Since they are paid to listen, we don’t have to feel guilty about “bothering and “burdening” them with our stories.

Psychological therapies can get better — and so can access to them

There’s still a lot that researchers would like to know about psychological treatments for chronic pain. One is that it’s hard to know which patients, and what types of chronic pain, they’ll work best for.

I’m sure CBT helps some pain patients, as do opioids, and either option could also be harmful in some circumstances.

When a CBT therapist tried to convince me that I was mentally creating my own pain so I’d feel justified in taking opioids and that I was just an opioid addict in “reality”, I lost all confidence in my own perception of my own experience, flooding me with feelings of helplessness and hopelessness – the opposite of the intended results.

A second is that it’s hard to know what exact component of these treatments is most beneficial. In clinical trials that compare CBT to an active control group (such as one that engages in another form of therapy, like exercise, physical therapy, education, or a support group), the benefits for pain disappear.

So many of the benefits of CBT are only “visible” when compared to doing nothing at all. It looks like any healthy attention to managing pain is helpful, not just CBT or even psychotherapy in general.

Of course, researchers already know what answers they want from their studies and these days, it’s all about trying to prove that opioids don’t work and therapy does.

By selecting the right comparisons, like CBT vs nothing instead of CBT vs Opioids, their pet cause can be made to look good.

These studies have to support the current cultural sentiment because that’s how they get funded.

That means CBT isn’t uniquely better at diminishing pain than other forms of therapy (though it’s still better than doing nothing).

However, compared to active controls, CBT does have an increased positive effect on catastrophizing and disability. And, as mentioned, these are key components to decrease suffering and pain in some cases.

CBT takes many hours of intensive one-on-one therapy. So Darnall is in the midst of a clinical trial to find out if just a two-hour class on pain catastrophizing before a surgery can help reduce pain post-operation.

If that works, it could be a small step toward reducing the need for opioids. “Real-world patients don’t have access to 11 weeks of CBT,” she says. “Insurance might not cover it, where are you going to find a psychologist, you can’t get off work. What I wanted to do was create something accessible, efficient, and low-cost.”

This is the typical response to any therapy or treatment that takes time – make it faster.

However, our brains and beings cannot “turn on a dime” to make long-lasting changes; those simply require time for the body and brain to shift. Otherwise, changes will be short-lived.

Indeed, therapy can get pricey. Palanker, the Georgetown health insurance expert, paid more than $100 a session out of pocket for mindfulness therapy for her pain. And CBT can cost $100 or more per hour of counseling.

We need medical and psychological treatments for pain. But we also need to recognize that medical treatments have been overused.

On the bright side, psychological therapies for pain are low-risk. The same cannot be said of medical treatments for chronic pain. Back surgery for lower back pain often backfires.

Doctors literally call this “failed back surgery syndrome” — around 20 percent of back surgery patients will still have chronic pain despite successful procedures, which can cost $50,000 or more.

The best pain treatment centers have psychologists, physical therapists, and physicians on staff who consult with one another and decide on the right course of medication and therapy.

But these centers are hard to find and theirwaitlists can be months long. It can be hard to convince patients who are looking for a quick fix to try psychotherapy.

The language here is tricky for doctors, too. There is a long and real history of people (particularly women) not being believed about their pain, and sometimes physicians do miss a crucial diagnosis. In her practice, Furlan says she never uses the phrase, “The pain’s in your head.”

“That will destroy your relationship with the patient,” she says. “They will never come back.” It’s dismissive of their experience, and it’s not the truth.

Instead, she explains, with psychotherapy,

“we’re trying to improve the person that has pain,
not just the pain the person has.”

I’m all for psychotherapy – it probably saved my life – but it wasn’t some simplistic standardized CBT treatment.

Instead, I worked with a series of therapists over decades. They helped me clarify my values, helped me understand why my behavior fell short of my values and showed me how to make myself stronger and wiser to overcome my weaknesses (like chronic pain).

My therapy was like learning how to repair an intricate clockwork, while CBT is like playing with tinker toys.

4 thoughts on “Psychotherapy for Chronic Pain

  1. leejcaroll

    bad example for author to use since, unless I skimmed it too quicklyl, the hand pain never had a diagnosis. So one has to wonder was there in fact a physical cause or was this a psychological mechanism for other issues in his life. Yes some folks have chronic pain that is the minds way of coping for most of us that is not the case. I have trigeminal neuralgia a facial pain disorder. It is provably caused by a brain birth defect yet I have been told more then once it is psychological. Usually the docs who tell me this havent a clue about tn, or the birth defect. tn a rare disease, the birth defect even rarer still. So what to do. I kno0w blame the patient/the patient’s psyche. CBT seems to be the new go to when they dont know what else to suggest.;

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  2. canarensis

    I’ve often wondered at the nerve damage pain (CRPS?) I got after they went in thru my ribcage to get a tumor off my esophagus in ’01. At the time, I had no idea it was possible for acute injury/surgical pain to become chronic. I expected it to go away, knew it would go away any day, just like other painful injuries & surgeries. So how does that fit in with the jerks who’ve told me that I only have the pain b/c I expected it to hurt & stay painful? I did the exact opposite of expecting it to stick around; I KNEW it was gonna go away…but it didn’t. But I still have doctors tell me that it’s not “real,” that the only reason I think there’s pain there is b/c I expected there to be pain….but I didn’t. I always want to superglue a permanent alligator clamp onto a tender body part of theirs & tell them to wait for it to stop hurting…tho it doesn’t REALLY hurt, it’s all in their mind…

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