The Psychology of Chronic Pain
It’s not all in your head… but you can retrain your brain to handle pain differently.
The pain started in Debbie Cook’s feet when she was a dancer in high school. Soon after, it spread to her hands, then eventually her neck and back. Cook, 45, from Hueytown, AL, sought out doctor after doctor to diagnose her traveling pain, but no one could. “At one appointment, the doctor pulled out his Rx pad,’ she recalls. “I asked him what he was writing. He said, ‘Lortab,’ (a commonly prescribed pain med) and I said, ‘Save your ink.’ He looked at me and said, ‘What do you want?’” Cook’s answer was clear: “To be fixed.”
At age 31, Cook was eventually diagnosed with rheumatoid arthritis and fibromyalgia. She has had periods of her life where the pain has been almost unbearable. “It got so bad I thought I was going to lose my mind,” she says. While medications like methotrexate and Simponi (golimumab) have been a game changer for her, Cook has also found relief through an avenue that might seem unlikely: cognitive behavioral therapy. “The psychology part of pain management has helped me as much as the Rx part,” she asserts. As a mom, Cook used to struggle with feeling like she wasn’t doing enough for her children or that she was a burden to others. She now sees her doctor monthly or every other month, and they talk about reframing her mindset about the circumstances she is dealing with. “She gives me multiple tools to deal with my everyday chaos,” Cook says. “Now I can function with the daily pain and not stay in a cycle of guilt. I have accepted that my normal is not the same as everyone else's normal.” And that, for her, has been essential to finding happiness again.
The Chronic Pain Epidemic
There’s no denying that chronic pain is a real and widespread affliction, affecting at least 50 million adults in the United States. It is associated with a myriad of health conditions such as autoimmune diseases, migraine, and cancer, but sometimes chronic pain has no identifiable origin or cause.
Treatments range from modern medical interventions to lifestyle adjustments to psychological approaches. “Pain always has biological, psychological, and social contributors, and they always interact,” says Robert Kerns, Ph.D., professor of psychiatry, neurology, and psychology at Yale University in New Haven, CT. This multifactorial lens provides a new way of looking at pain as something beyond just a physical sensation.
What Is Pain?
To understand something as conceptual and personal as pain (and what makes it chronic), let’s talk terminology. The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Notice that sensory and emotional are both used to describe pain. The event that caused the pain is different from the pain itself.
Acute pain is a specific bodily response to a clear trigger (like when you burn your hand on the stove). “The pain is secondary to the injury and acts as a warning sign, like a fire alarm,” says Alison Vargovich, Ph.D., clinical psychologist and assistant professor of behavioral medicine at the University of Buffalo in New York. This contrasts with chronic pain, which is drawn-out and doesn’t always have a clear trigger. “Pain is no longer a symptom, but a disease affecting the central nervous system, brain, and spinal cord,” Vargovich says. You’re feeling pain when there is no serious physical danger. “In essence, our fire alarm is malfunctioning. It is going off because one birthday candle is lit, which is not helpful.”
Of course, sometimes chronic pain is indicative of a serious issue in your body, like an injury or illness. Therefore, it is always important to see a doctor when you’re dealing with lingering pain of any kind. But when the pain arises from something that can’t be totally cured—like endometriosis cramps or rheumatoid arthritis morning stiffness—it helps to know that you can retrain your brain to process these neurological pain signals differently.
The Pain Brain Loop
“Pain is complex, and it’s a subjective human experience,” Kerns explains. “Everybody has an idea of what it is because we all have experienced it.” Your feelings around pain are tied to a lifetime of memories, emotions, and social context. “When somebody has a chronic pain condition, their experiences over a lifetime are likely in play in terms of how they experience pain.”
For Cook, her RA flares limited her mobility—and as a mom of two young children, this added immense stress to her life. “I felt like I was struggling to keep my head above water every second of the day,” she says. “I couldn't sleep because I would lay down and stress about how I was going to care for my kids or how I would be able to do anything with my kids with me.” It got to the point where she was stressing about her stress, and the chronic inflammation triggered by that stress only contributed to the pain/stress cycle.
Vargovich refers to this as a “neurological pain loop” that can be difficult to break on your own. “It’s like walking a shortcut through a lawn,” she says. “The more times you walk it, the more worn in it gets and easier it is to find.” The only way out is to forge a new path.
Psychological Approaches to Treating Pain
Medical pros of all stripes—from MDs to psychologists to physical therapists—are using these psychological strategies to help patients manage their chronic pain. “We’re all trying to help people challenge their false beliefs and promote what we call adaptive pain self-management,” Kerns says. The goal is to “challenge maladaptive thoughts or promote a sense of self-acceptance and accommodation.”
Here are two of the most common and well-studied methods:
Cognitive behavioral therapy (CBT): Long recognized as the gold standard for treating anxiety and depression, CBT is focused on challenging irrational ways of thinking. This can also be a useful tool for people with chronic pain. “Cognitive behavioral therapy is the approach that has the longest history and strongest evidence of benefit in terms of helping people reduce their pain intensity, but also [helping to] reduce the interference of pain with daily functioning and emotional well-being,” Kerns says. While you might not be able to remove the sensory experience of pain, you can remove your emotional reaction to it, breaking that cycle of stress that only makes the pain worse.
During a CBT session, your therapist might ask questions like, “What evidence do you have for that thought? Is there evidence contrary to this? Is the outcome within your control?” The idea is to help you understand that the past and the present are not necessarily tied and that your emotional reactions are not always based on logic. CBT is generally done with a therapist, requires five to 20 sessions, and can be accessed on popular apps like Talkspace or BetterHelp.
Acceptance and commitment therapy (ACT): This type of therapy focuses on reaffirming your negative attention in a more positive direction. It uses mindfulness to help you stay rooted in the here and now. “It’s taking advantage or people’s values and personal goals and encouraging them in a more positive direction to act even despite their pain,” Kerns says. This approach is newer than CBT but is also supported by a growing body of research-backed evidence for the treatment of chronic pain. It might be a bit harder to find than CBT, but not impossible—you can filter results on the Psychology Today website to find a therapist that specializes in ACT.
How popular are these approaches? Kerns and Vargovich both say they are growing in popularity but still underutilized. Vargovich attributes this to “a lack of understanding of how to best manage chronic pain and difficulty accessing these services for patients.” Education and access, she says, are key to making sure more people can take advantage of these treatments.
Kerns agrees. “Fifty million people in this country have chronic pain, and there are not enough psychologists with that expertise,” he says. “Access is a huge issue, placing many people in our country at a disadvantage.” The rise of telehealth associated with the COVID-19 pandemic is certainly helping, but it won’t solve the treatment gap overnight. (If you believe in these types of treatments, it’s important to advocate for them at your job, with your health insurer, and in your community!)
Who Can Benefit?
Psychological treatments for pain are not for everyone, and they shouldn’t be your only method of pain management. These approaches “tend to be most effective for patients suffering from centralized pain conditions, such as fibromyalgia, irritable bowel syndrome, and chronic tension headaches,” Vargovich says. “More peripheral pain conditions, like osteoarthritis, may not benefit from these treatments as much, unless the person is struggling to cope with the pain or has difficulty maintaining daily functioning.”
Essentially, the more your pain disrupts your daily life, the more likely you are to get a benefit from these types of treatments. Cook found CBT to be life-changing because it helped her better understand what she can and can’t control. “I have the tools to help me through the really bad days, and my worth is not determined by what I am physically able to do,” she says. “Some days my best is getting my kids to and from school. Some days I can get some chores done; some days I can't. I own my pain, but it does not define who I am.”
Kerns emphasizes that chronic pain is complex and requires a multi-modal approach to treatment. “Psychological approaches, physical therapy, and medicines are all likely to be insufficient in and of themselves,” he says. And you won’t be cured with just one session, either. Instead, think of this as a long-term strategy for learning to live and thrive despite your chronic pain.
- Chronic Pain Prevalence: Centers for Disease Control and Prevention. (2018). “Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016.” cdc.gov/mmwr/volumes/67/wr/pdfs/mm6736a2-H.pdf
- Pain Definition: International Association for the Study of Pain. (n.d.). “IASP Terminology.” iasp-pain.org/Education/Content.aspx?ItemNumber=1698
- Cognitive Behavioral Therapy: American Psychological Association. (n.d.). “What Is Cognitive Behavioral Therapy?” apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
- Acceptance & Commitment Therapy: Association for Contextual Behavioral Science. (n.d.). “Acceptance & Commitment Therapy (ACT).” contextualscience.org/act/
- CBT for Chronic Pain: American Psychological Association. (2014). “Cognitive-Behavioral Therapy for Individuals With Chronic Pain.” apa.org/pubs/journals/releases/amp-a0035747.pdf
- ACT for Chronic Pain: Clinical Journal of Pain. (2017). “Acceptance and Commitment Therapy (ACT) for Chronic Pain: A Systematic Review and Meta-Analyses.” pubmed.ncbi.nlm.nih.gov/27479642/