Why See a Psychologist for Pain? (Part 2)


In the last post, we addressed the question, “Why see a psychologist for pain?” The answer is that psychologists are the experts in teaching patients how to self-manage and cope with chronic pain. Patients who see psychologists for chronic pain can learn how to self-manage and cope with pain so well that they can largely come to live a normal life despite having chronic pain.

 

Another way to respond to the question of “Why see a psychologist for pain?” is to look at the role of the nervous system in chronic pain and how psychologists are experts in the treatment of health problems related to the nervous system. Let’s attempt to unpack this statement.

Nervous system & chronic pain

People commonly think of chronic pain as if it is a long-lasting symptom of an injury or illness that has failed to heal. This viewpoint is mistaken. Take, for example, the notion of degenerative disc disease. It is common to think that degenerative changes of the spine are the cause of chronic back pain. However, we know that degenerative changes of the spine are only minimally correlated with pain, which means that most of what makes up the experience of pain cannot be attributed to degenerative changes of the spine (Endean, Palmer, & Coggon, 2011). Such changes of the spine are a minor ingredient, if you will, in the pie that’s chronic pain.

A more accurate understanding of chronic pain is that it is a disorder of the nervous system called “central sensitization.” An orthopedic injury, for example, might have initially caused a case of back pain, but now, after many months or years, the whole nervous system is involved, including the brain and spinal cord. Changes to the whole nervous system have now made the nerves at the original site of the injury highly sensitive and reactive. They are stuck, as it were, in a “hair trigger” mode that makes any little movement painful.

In the notion of central sensitization, we also see one of the central tenets of chronic pain rehabilitation: that when it comes to chronic pain, what initially caused the pain is not now the only thing that maintains pain on a chronic course. The notion captures the complexity of causal factors in chronic pain, as opposed to acute pain, which may have one cause – an injury or illness. Biological, psychological, and environmental factors are known to influence the development of central sensitization (please see the Institute’s content page on central sensitization for more details). The notion of central sensitization also explains other psychosocial aspects of chronic pain – chronic fatigue, insomnia, limited cognitive deficits such as poor concentration and short-term memory, gastrointestinal upset, anxiety, and depression (Meeus & Nijs, 2007; Wieseler-Frank, Maier, & Watkins, 2005; Yunus, 2007)

For many years, psychologists have successfully treated patients with health conditions related to the nervous system: depression, the various anxiety disorders, insomnia, irritable bowel syndrome, as well as chronic pain.

Psychological therapies for chronic pain

The Society for Clinical Psychology, which is a division of the American Psychological Association, developed task forces to compile a list of treatments that have been determined to be effective for a variety of disorders. They defined “effectiveness” as having multiple clinical trials from different researchers showing the effectiveness of a specific treatment. Not surprisingly, they have identified as effective multiple psychological treatments for mental health disorders such as depression, post-traumatic stress disorder, panic disorder, obsessive compulsive disorder, and general anxiety. However, they have also identified as effective multiple psychological therapies for health conditions. There is strong empirical support for cognitive behavioral treatments for chronic low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia, headache, and chronic pain syndromes in general. They have also identified effective psychological therapies for primary insomnia and irritable bowel syndrome. You can find information on these treatments here and here.

These therapies are effective likely because of their impact on the nervous system. Just as cognitive behavioral therapies reduce the reactivity of the nervous system in persons with post-traumatic stress disorder or panic disorder, in terms of their heightened startle response or susceptibility to panic, respectively, cognitive behavioral therapies for chronic pain disorders are likely to reduce the reactivity of the nervous system. By reducing the reactivity of the nervous system, patients come to have less pain and increased abilities to cope with the pain that remains.

References

Endean, A., Palmer, K. T., & Coggon, D. (2011). Potential of MRI findings to refine case definition for mechanical low back pain in epidemiological studies: A systematic review. Spine, 36, 160-169.

Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

Wieseler-Frank, J., Maier, S. F., & Watkins, L. R. (2005). Immune-to-brain communication dynamically modulates pain: Physiological and pathological consequences. Brain, Behavior, & Immunity, 19, 104-111.

Yunus, M. B. (2007). The role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Practice Research in Clinical Rheumatology, 21, 481-497.

Published date: 7-29-2013

Date of last modification: 7-29-2013

Author: Murray J. McAllister, PsyD

Why See a Psychologist for Pain?

Patients can sometimes question why their physician wants them to see a psychologist for pain. The concern, of course, is that they are going to get stigmatized. They might wonder, “Doesn’t my doctor not believe me?” or “Do they think it’s all in my head?” This understandable reaction can often prevent patients with chronic pain from seeking the care of a psychologist. It is, however, unfortunate. Among all healthcare providers who specialize in the treatment of chronic pain, psychologists provide some of the most effective therapies. Patients can fail to benefit from them when they fear stigma and fail to follow-up on recommendations to obtain psychological care.

Psychologists have a long tradition of providing chronic pain management. Psychologist were integral to the development of chronic pain rehabilitation programs thirty to forty years ago and have been either running them or working in them ever since. As described in previous posts (such as this one here), chronic pain rehabilitation programs are commonly considered among healthcare providers to be the most effective treatment option for people with chronic pain.

To get such care, though, it’s helpful to know what psychologists do when seeing patients for chronic pain. In this post, and the next, we will explore the answer to the question: Why see a psychologist for chronic pain? We will answer this question from two broad perspectives.

First, in this post, we will look at the answer from the perspective of the role of coping and self-management. Second, in the next post, we will explore the issue from another perspective. Namely, we will look at the answer from the perspective of the bodily organ system that is most responsible for chronic pain – the nervous system.

So, the quick answer to the question of why you should see a psychologist for chronic pain is the following:

  • Among all healthcare providers who treat chronic pain, psychologists are the experts in teaching patients how to cope with and self-manage pain.
  • Psychologists are experts in the treatment of nervous system problems and chronic pain is largely the result of nervous system disorders.

Let’s now look at the first answer in a little more detail. We’ll look at the second one in the next post.

Self-management of pain

All experts (and most patients, by the way) agree that to successfully manage chronic pain patients must be active participants in their care. That is to say, they have to learn effective ways to cope with and self-manage pain. It’s as true of chronic pain as it of other common, chronic diseases. Most everyone would agree that patients with heart disease or diabetes wouldn’t manage their disease successfully if they themselves didn’t engage in self-management: who would argue with the importance of maintaining a healthy diet, weight loss, exercise, and stress management, among other health behaviors, in the successful management of these diseases? Similarly, most everyone accepts that patients have a role in the successful management of their chronic pain syndrome. Successful management requires the ability to self-manage and cope with pain very well. But where do chronic pain patients learn how to do it?

Patients with chronic pain seek care from many different types of providers, all of whom specialize in the management of chronic pain. However, it’s only one kind of chronic pain provider who specializes in teaching patients how to self-manage and cope with pain.

Typically, it is not spine or orthopedic surgeons. Surgeons tend to have relatively brief appointment times with their patients and they tend to focus on surgical procedures and how to aid in recovering from such procedures. Now, certainly, there may be a time and place for the care of a surgeon. The point here is not to criticize surgeons or surgery. Rather, it is simply to point out that the focus of surgeons is typically surgery, not in teaching patients how to cope with and self-manage chronic pain.

It is also typically not the role of interventional pain physicians. Their appointment times are also commonly brief and focused on providing injections and other minimally invasive procedures. The point is not a criticism. Rather, the point is that their focus lies elsewhere. It is not on spending time with patients and teaching them how to cope with pain well.

It is also typically not the provider who prescribes opioid pain medications on a long-term basis. Of course, there can be exceptions, but most such providers have relatively brief appointment times, usually around fifteen minutes. The focus of much of this time is on obtaining updates about your well-being since your last appointment and on how well the medications are working. There is not a lot of time left over for teaching, clarifying, and reviewing strategies for coping and self-management. Again, the point is not a criticism. It’s simply that the focus of prescribing providers is typically on managing the medications and not on teaching patients how to self-manage pain without the medications.

All these providers typically know it too. It’s why they tend to refer chronic pain patients to pain psychologists.

So, where do you go to learn how to self-manage and cope with pain well? You go to healthcare providers who specialize in teaching patients how to do it. You go to health psychologists and you find them in chronic pain rehabilitation programs.

Health psychologists have been running chronic pain rehabilitation programs for the last thirty to forty years. You can find such programs throughout the world. Research consistently shows that they are one of the most effective treatment strategies for chronic pain (see, for example, this article here).

They are so effective because they focus on teaching patients how to self-manage and cope with pain very well. Self-management and coping very well are essential to manage chronic pain successfully.

Most patients, though, have to learn how to do it. Such learning requires appointment times that are longer than fifteen minutes or so, and more frequent than once a month or so. It also requires having a good, solid, therapeutic relationship with an expert provider who listens to you and gently coaches you over time on how to do it. You find such care with a health psychologist who works in a chronic pain rehabilitation program.

It’s possible to self-manage and cope with chronic pain very well. You just have to learn how to do it. And you learn from a health psychologist. It’s why you would see a psychologist for chronic pain.

Author: Murray J. McAllister, PsyD

Date of last modification: July 1, 2013