Surprise, surprise: many patients with physical pain also experience emotional pain. This mind-body connection is strong for chronic pain. This is why so many pain clinics recognize an important roll of psychology in chronic pain and integrate mental health into chronic pain treatment.
This integration often seems strange to patients. Sometimes patients believe therapists are going to say that pain is all in their head. Or that therapists exist to take their pain meds away. But therapists have an entirely different role in pain treatment.
Pain psychology includes therapist assessment for substance abuse. Similar to PTSD, depression, and anxiety disorders, comorbid substance abuse is common with pain conditions. But substance treatment is usually less of an emphasis than pain patients believe. Most pain provider medication contracts lead patients with substance issues to be disqualified from their care before even seeing a pain doc’s behavioral provider(s). Those patients may end up in substance treatment somewhere else.
Back to that mind-body connection: where mental health therapists help patients cope with the difficult pain experience. This mind-body connection is not as simple as “yeah duh, of course the mind connects with the body”, however. There are specific complex avenues in the psychology of chronic pain for which mental health interacts with physical health to inform pain treatment.
The first avenue concerns lifestyle and activities. Pain often prevents people from doing desired work or hobbies. Some patients stop all manner of activities, even non-strenuous ones. This puts them at high risk for depression, because they lose contact with sources of meaning or reward in their lives.
The second avenue concerns emotional reactions to pain. Pain is legitimately frustrating, anger provoking, or anxiety provoking (among other emotions). Those emotions involve increased sympathetic nervous system activation (similar to the “fight or flight” in trauma/PTSD). This activation includes increased heart rate, blood pressure, and/or muscle tension. Sympathetic activation hits on areas of the body where people experience pain (e.g., back or neck pain), and makes that pain worse for some patients.
Third, pain is real; it’s not just all in your head. But difficulties with depression or emotional coping (or both) often lead patients to focus more on the source of those difficulties: their pain. Increased focused on pain sensations makes the experience worse – they are just always thinking or ruminating about their pain.
Interestingly, research finds that when people experience more of these psychological difficulties with pain, perception of pain in the brain is disrupted. That is, increased pain pathways and decreased ability to regulate pain that actually visible in brain imaging!
Cue therapists and their resources to help target the source of those difficulties. For example, behavioral activation shows initial promise for the psychology of chronic pain. It helps people find meaningful or rewarding activities and hobbies that minimally impact pain and helps prevent depression. Behavioral activation trainings for therapists are easily applicable to chronic pain treatment.
CBT for chronic pain helps patients talk themselves through difficult emotions like frustration or anger. This approach effectively minimizes emotional distress and sympathetic activation, which in turn, minimizes pain. CBT’s emotional coping skills and perspective-taking skills also help patients decrease attentional focus on pain and challenge negative beliefs about the power pain has over their lives.
There is a ton of CBT training out there: both CEs for CBT fundamentals and for CBT applied to chronic pain. There are also good resources for therapist and patients to build coping strategies for pain. The VA even put out a free handy CBT for Chronic Pain Manual. Tech companies also pitched in with virtual reality platforms for pain treatment.
Chronic pain is literally and emotionally a pain. Luckily the psychology of chronic pain is an area where mental health therapists have plenty of resources to make a huge impact!
