In Chronic Pain? You Might Need Psychotherapy

Video: Aching Back Pain

When people with chronic pain are advised by their physician to see a therapist, many balk at the idea. They often assume the message is that their pain is imaginary, all in their heads. But the services that a psychologist can offer—cognitive behavioral therapy and biofeedback, for example—can ease the misery by helping people learn to cope, says Robert Kerns, a professor in the department of psychiatry, neurology, and psychology at Yale University. Kerns was coauthor of a 2007 review published in Health Psychology that found psychological interventions to have a positive effect on the chronic low-back pain that afflicts at least 70 percent of adults at some point during their lifetimes. The review authors examined 22 studies and found that cognitive behavioral therapy and self-regulated treatments (such as biofeedback and hypnosis) eased pain intensity, improved quality of life, and reduced symptoms of depression.

People sometimes report chronic pain continuing for months or years after an injury, illness, or surgery. The original cause of the pain has healed, yet the person still hurts. And these people are not "manufacturing the pain," says Dave Patterson, professor of psychology in the department of rehabilitation medicine at Harborview Medical Center at the University of Washington.

There are several different mechanisms, he says—among them that when people stop moving and/or guard their bodies because of pain, even after they heal, the lack of movement and the way they guard their bodies can cause pain. Also, after someone has experienced pain for a long time, Patterson says, "the brain seems to become rewired so that it responds as if the person is in pain, even though the initial injury might have healed."

That's where psychological interventions can be useful. Besides cognitive behavioral therapy and biofeedback, treatments may include meditation, guided imagery, and hypnosis, among others. The goal, says David Bresler, president of the California-based Academy for Guided Imagery and founder of the UCLA Pain Control Unit, is to teach people how to relax, raise their tolerance to pain, and better manage the stresses in their life. These techniques "don't cause dependence or addiction," which can be a concern with narcotic pain medications, notes Bresler. "We believe that guided imagery," for example, can be used to elevate the "production and release of endorphins, the body's most powerful, natural pain relievers." Guided imagery, which involves focusing intently on relaxing images in your mind, has been used for treatment of pain, addictions, anxiety, phobias, panic disorders, cancer, depression, fertility problems, post-traumatic stress disorder, and other problems.

Psychological counseling can also foster good sleep habits, improve functioning and quality of life, and help people learn how to pace themselves. Many people with chronic pain say they feel worse when they sleep poorly or overdo it on work, school, or social activities. And "we do know that if people can reduce stress and sadness in their lives, learn to become physically active in a safe manner, and constructively alter the internal thoughts they have about their pain, that they can tolerate it much better regardless of its origin," Patterson says.

Among the tools used to accomplish this is cognitive behavioral therapy, a mainstay of psychological treatment that involves "breaking big problems into bite-size pieces, [which helps] in terms of improving coping and using stress management techniques," says Robert Jamison, a clinical psychologist and associate professor at Harvard Medical School. CBT can teach people living with chronic pain that "how they think about their pain can make it worse," Patterson says. "If they catastrophize, with thoughts like 'My pain will never go away, I will always feel like this, I'm going to die because of this pain,' " that can make a person feel more miserable. So therapists teach patients to "modify their thoughts about the pain and replace them" with more positive thoughts, he says.

What's important to realize, Kerns says, is that the experience of seeing a therapist isn't like what you see on the movies or television. People "should know that it's a brief treatment, usually delivered in an average of 10 outpatient treatment sessions, typically delivered once a week, for less than an hour each," he says. "The treatment itself is more like a class, very focused on their pain, individually tailored to their problem and how their problem is impacting their functioning, and it's designed to provide them with real-life skills for improving their own management of their pain."