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Pain: Finding the Way Forward with Psychology

This blog is written by Luke Parrott, Clinical Psychologist, Persistent Pain Management Service, Peninsula Health. 

With more than one in five people experiencing persistent pain it is quite likely that either you or someone you know suffers with it. Pain that goes on long after the tissues of the body are expected to heal following an injury or that seemingly appears out of nowhere and continues on without any discernible triggering incident can be both perplexing and troubling for the sufferer.

Most commonly, and understandably, people will consult medical professionals to investigate the source of pain and seek interventions to fix it.

With acute pain this can be effective, however, the evidence tells us that when pain persists the strategies employed to help people with acute pain – rest, medications, surgeries, and other tissue-based interventions – are frequently ineffective on their own and all too often a vicious cycle develops that can result in escalating medication use, increasing vigilance to sensory experiences, reduced participation in activities, frustration, anxiety, and misery.

The mentioned strategies often don’t work because of something that pain scientists and clinicians have known for many years yet is still less widely understood in the community – persistent pain is less about the state of the tissues of the body and more about sensitivity of the brain and the spinal cord. Ultimately, it is the brain that gives us the experience of pain. The brain decides. One hundred percent of the time.

It is not in your head

The brain can produce pain, along with a number of other protective responses, when it weighs up the evidence at hand and decides there is a threat. Although the processes are complex, in simple terms the brain receives messages from the bodily tissues and subconsciously asks the question “Is this message dangerous or safe?”

If the brain deems the messages safe it might do nothing. If it deems the messages dangerous it is likely to initiate pain, more inflammation, a stress response, protective immune responses or a combination of all of these. The brain uses a vast array of information to conduct this evaluation such as memories, emotions, thoughts, beliefs, knowledge, the context in which it occurs, postural information, and environmental factors. It all happens in the blink of an eye outside of our conscious awareness.

One of the most common misconceptions that spring forth when pain sufferers first hear that their pain might reflect sensitive protective processes in the brain is “They think it is in my head”. Much of the work of the effective pain practitioner is to dispel this myth, help people understand that their pain is absolutely real yet educate them on the wide and varying factors that contribute to why they might feel the pain they do aside from issues in the tissues. This is where psychologists can play an important role.

How do psychologists help with persistent pain

Psychologists can assist people living with persistent pain to explore their pain story and to make useful links between difficult life events and protective nervous system responses. In the face of significant challenges the nervous system can become primed to protect so it is not uncommon for those who have faced great adversity to experience anxiety, worry, chronic bodily tension, and even persistent pain as the system tries harder to remain safe.

These are all protective responses that can continue after difficult events have long since passed. Understanding this and working on skills to manage the array of cognitive, physiological and emotional symptoms that can arise, as well as building on coping skills can be useful. Psychologists can help with this process.

Certainly not all people who live with persistent pain have experienced emotionally traumatic events, however, most can identify other factors that might have impacted their emotional health. Periods of high stress, work pressure, relationship difficulties, grieving the loss of a loved one, feeling invalidated by others, navigating insurance and compensation processes, feeling unable to participate in valued activities, or simply worrying about what the future might hold, among a myriad of other things, are commonly reported by persistent pain sufferers. Any of these challenging experiences can prime the brain to protect, essentially turning the volume dial up on pain.

Psychologists are primarily interested in human thought, emotions, and behaviours in one form or another. Pain psychologists are often particularly interested in the thoughts and beliefs that pain sufferers express. When it comes to pain, the language used to describe it can be a window into the person’s inner experience. Statements such as “I hate this”, “When will this go away?”, “They must have missed something”, “It doesn’t feel like my leg anymore”, “I only have to think about moving and it hurts” are completely understandable human responses yet often reflect an intense struggle that can underpin the process of pain persisting.

These thoughts are nerve impulses in the brain and are incorporated with the information that the brain uses to decide whether or not to protect. Therefore, our language, thoughts, and beliefs about pain can influence our experience of pain. Pain psychologists understand this and work with people to assist them to recognise less helpful thinking patterns, reconceptualise pain, and develop more helpful ways of both thinking about their pain experience and responding to the sensations they feel.

Psychologists can help address the “What if? question and the resulting fear and anxiety that so often plagues people wanting to expand their worlds yet are feeling apprehensive about what might happen to them if they do.

Psychologists are key components of all good modern pain programs. Many clients who are referred to psychology during their time with the Persistent Pain Management Service at Peninsula Health are relieved and surprised when they are not asked to lie on a couch by a bespectacled man stroking a goatee beard saying “Tell me what you are thinking about.”

Antiquated ideas of what is psychology persist. So, specifically, what kinds of things might a pain psychologist do I hear you ask.

  • Education: explain how thoughts/beliefs, emotions, and behaviours can influence pain
  • Make useful links between difficult life experiences and pain
  • Goal setting and exploring values
  • Help build cognitive (thinking) skills for dealing with difficult or unhelpful thoughts. These might include:
    • Mindfulness based skills – Just noticing thoughts and not getting caught up in them
    • Cognitive reframing – challenging unhelpful or erroneous beliefs and developing more helpful ways of thinking
    • Developing positive/affirming self-statements and positive metaphors
  • Teaching the body to relax through:
    • Progressive muscle relaxation
    • Deep breathing techniques
    • Active relaxation i.e. gentle movement, bath, music, dance etc
  • Teaching mindfulness skills to promote less reactivity to emotions, and sensations including pain
  • Stress management skills
  • Coping skills
  • Problem solving skills
  • Addressing the barriers to increased participation in valued activities including fear/anxiety, and reduced confidence

Connecting with a psychologist either in the community or via a pain management program might offer some different perspectives and assist you to take steps forward and regain a sense of control.

Further information and resources

Why Things Hurt – Ted Talk by Lorimer Moseley – https://ed.ted.com/on/Li50Ci7S

Tame the Beast – video and other pain resources – https://www.tamethebeast.org/

Book: Explain Pain, Neuro Orthopaedic Institute, Noigroup Publications, 2013: Available via www.noigroup.com

Mindspot Pain Course – https://mindspot.org.au/pain-course

Australian Clinical Psychologist Association – Find a clinical psychologist https://acpa.org.au/find-a-clinical-psychologist/

Psychology Week runs from 8 November, this year promoting the role of psychology in helping people with pain. If pain is a problem in your life consider speaking with your GP about all of the available options.