In Chronic Pain? You Might Need Psychotherapy

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.

Video: Aching Back Pain

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."

Here's a look at three other common treatments:

Meditation—the act of focusing attention on your breath, an object, or a word, or maintaining a specific type of posture—is intended to relax the mind and body. Goals of the technique include achieving psychological balance, mental calmness, or physical relaxation, according to the National Center for Complementary and Alternative Medicine. Scientists don't know whether meditation has a positive impact on health, but studies are underway to find more answers about how helpful it might be and, if so, for which diseases or conditions. The technique seems to reduce stress, which may result in decreased pain.

Hypnosis is a focused type of concentration. It may involve saying a positive statement repeatedly or, in the case of guided imagery, thinking of relaxing images. It's considered to be a simple yet effective method of pain reduction for many people, as noted by the National Library of Medicine. The technique has been tried for relief of pain after surgery or during labor and for pain caused by arthritis, cancer, fibromyalgia, irritable bowel syndrome, and headaches.

Biofeedback measures blood pressure, breathing, heart rate, muscle tension, and skin temperature. The goal is to adjust these bodily functions through relaxation techniques or by thinking of pleasing images. As these levels are shown on a screen, the practitioner working with you talks about stressful situations and then provides instructions on techniques for relaxation, in an effort to show you how your blood pressure and heart rate react. The goal is for people to learn how to apply these techniques in real life when they feel themselves becoming stressed. Biofeedback is thought to help with chronic pain as well as high blood pressure, headaches, and urinary incontinence.