Conceptualization and Treatment of Chronic Pain
Written By: Sarah Grace Uhouse, M.S., doctoral candidate in clinical psychology at Rutgers, The State University of New Jersey
Chronic pain is a pervasive and burdensome problem in the United States. While some estimates report that approximately 50 million adults in the United States endorse experiencing chronic pain (Gatchel et al., 2007), other estimates indicate that the true number may exceed 100 million (Boehnke et al., 2019). Chronic pain is one of the principal causes of disability (Stockings et al., 2018), and the annual estimated cost in the United States is approximately $635 billion dollars (Boehnke et al., 2019). The factors that contribute to this alarming number include health care costs, such as frequent health care utilization, and occupational costs, such as days absent, decreased productivity, and inability to work (Gatchel et al., 2007; Hughes et al., 2017). As mental health clinicians, it is vital to understand both the factors that contribute to the development of chronic pain, as well as the psychological treatments available to patients.
To conceptualize chronic pain appropriately, it is helpful to distinguish it from acute pain. Acute pain is conceptualized as an adaptive process, signaling to the body that there is damaged tissue (Meulders, 2019). With acute pain, the body experiences heightened arousal and an implementation of a set of behaviors necessary to promote healing, such as rest and avoidance of problematic movements (Meulders, 2019). In certain individuals, pain persists and becomes chronic. Chronic pain, on the other hand, is defined as pain that persists for at least three months (Gatchel et al., 2007). With the transition from acute to chronic pain, the state of heightened arousal persists, and many of the previously adaptive healing behaviors may transition to maladaptive safety behaviors, such as restriction of movements or certain activities. Thus, interventions must target not only the biological factors thought to contribute to the chronic pain, but also the maladaptive cognitive and behavioral patterns that maintain this state. Psychological interventions targeting cognitions and behaviors are therefore critical components of chronic pain treatment. However, for many years, opiates have been utilized as the first-line – and sometimes only– treatment for chronic pain (Chou et al., 2015). Given that approximately 42,000 individuals in the United States died as a result of opioids in 2016 alone, there is a clear need for the implementation of alternative treatments (Dowell, Haegerich, & Chou, 2016). Psychologists adept at treating chronic pain are therefore in a unique position to not only combat the suffering associated with chronic pain itself, but also potentially reduce opiate-related morbidity and mortality.
Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT) and mindfulness-based interventions (MBIs) have been shown to be effective for the treatment of chronic pain (Ball et al., 2017; de C Williams; Hughes et al., 2017). CBT focuses on addressing the problematic behavioral patterns, such as avoidance of movement and withdrawal from social/occupational situations, through the use of exposure techniques (Meulders, 2019). Behavioral interventions, such as CBT for insomnia and behavioral activation, to address secondary problems such as poor sleep and depressed mood respectively, can also be beneficial for patients. Catastrophic cognitions related to pain and its consequences, such as “What if I am in pain for the rest of my life?” and “Will I ever be able to do X again?”, are targeted through the use of cognitive restructuring (Ehde, Dillworth, & Turner, 2014). Overall, CBT may be an effective and acceptable treatment for chronic pain patients, especially if they have co-occurring psychological problems as well.
Like CBT, ACT targets experiential avoidance and problematic thought patterns. However, its mechanism of change relies primarily on increasing psychological flexibility through six core processes: acceptance, cognitive diffusion, values-based action, contact with the present moment, observer self, and committed action (Hughes et al., 2017). Patients are encouraged to focus on accepting the reality of living with chronic pain and engaging in activities in line with their values despite the pain, rather than focusing on reducing the severity of the pain itself (McCracken & Vowles, 2014). As such, ACT has been shown to exhibit large effect sizes for improvement in pain acceptance and psychological flexibility (Hughes et al., 2017). Given the theoretical orientation of ACT in emphasizing acceptance and commitment to valued actions, it may be helpful for patients to comprehend the theory and rationale of this treatment for chronic pain prior to engaging in it.
MBIs rely on the implementation of mindfulness strategies, defined as tools that enhance focus on the present moment without judgement and without trying to change the moment (Kabat-Zinn, 2003). In the practice of mindfulness, a patient’s maladaptive catastrophic thinking of the future consequences of chronic pain (i.e. “What if I’m never able to walk upstairs again?”) are addressed through contact with the present moment. Additionally, enactment of feared behaviors, such as specific movements, is encouraged to be practiced with a curious, nonjudgmental mindset, such as with the understanding that pain intensity may vary moment to moment or movement to movement (Day et al., 2014). Other techniques to practice mindfulness such as urge surfing, yoga, and meditation are considered fundamental to MBIs. Collectively, MBIs have been shown to improve chronic pain, as well as chronic pain-associated distress (Ball et al., 2017).
In sum, psychological interventions are a critical component of chronic pain treatment. They are both effective and provide alternative treatments to opiates, which have well-documented risks such as dependence and overdose (Chou et al., 2015). Importantly, the combination of psychological interventions with careful medication management through the utilization of an integrated healthcare team may lead to the best therapeutic outcomes for patients (Watt et al., 2006). Although a discussion of pharmacological treatments for chronic pain is outside the scope of this article, psychologists treating chronic pain patients should be familiar with commonly used medications and side-effects. While treating chronic pain patients can be difficult at times, given the intense suffering often associated with unrelenting pain, being able to provide effective psychological interventions to these patients can also be extremely rewarding.
Ball, E. F., Nur Shafina Muhammad Sharizan, E., Franklin, G., & Rogozińska, E. (2017). Does mindfulness meditation improve chronic pain? A systematic review. Current Opinion in Obstetrics and Gynecology, 29(6), 359-366.
Boehnke, K. F., Scott, J. R., Litinas, E., Sisley, S., Williams, D. A., & Clauw, D. J. (2019). Pills to Pot: Observational Analyses of Cannabis Substitution Among Medical Cannabis Users With Chronic Pain. The Journal of Pain, 20(7), 830-841.
Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of Internal Medicine, 162(4), 276-286.
Day, M. A., Jensen, M. P., Ehde, D. M., & Thorn, B. E. (2014). Toward a theoretical model for mindfulness-based pain management. The Journal of Pain, 15(7), 691-703.
Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. Journal of the American Medical Association, 315(15), 1624-1645.
de C Williams, A. C., Eccleston, C., & Morley, S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews, (11).
Ehde, D.M., Dillworth, T.M., & Turner, J.A. (2014). Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for future research. American Psychologist, 69(2), 153.
Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological Bulletin, 133(4), 581.
Hughes, L.S., Clark, J., Colclough, J.A., Dale, E., & McMillan, D. (2017). Acceptance and commitment therapy (ACT) for chronic pain: A systematic review and meta-analyses. The Clinical Journal of Pain, 33, 552-568.
Kabat‐Zinn, J. (2003). Mindfulness‐based interventions in context: past, present, and future. Clinical psychology: Science and practice, 10(2), 144-156.
McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178.
Meulders, A. (2019). From fear of movement-related pain and avoidance to chronic pain disability: a state-of-the-art review. Current Opinion in Behavioral Sciences, 26, 130-136.
Stockings, E., Campbell, G., Hall, W. D., Nielsen, S., Zagic, D., Rahman, R., & Degenhardt, L. (2018). Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis.
Watt, M. C., Stewart, S. H., Lefaivre, M. J., & Uman, L. S. (2006). A brief cognitive‐behavioral approach to reducing anxiety sensitivity decreases pain‐related anxiety. Cognitive Behaviour Therapy, 35(4), 248-256.