Despite our impressive knowledge of the neurophysiology of pain and the multitude of options we have to treat it, chronic suffering and disability from pain are more prevalent than ever. There is growing awareness of the need to understand both the physical and psychosocial factors that deeply affect pain. Chronic pain is now understood to be a disease of the central nervous system , a problem of overactive pain perception and/or under active pain modulation. When treating the chronic pain patient, the provider must acknowledge the psychological environment that directly precipitates, magnifies, and prolongs a pain experience. In certain cases, the notion of permanently “curing” a patient’s pain is an unrealistic goal for both the individual patient and the provider, a goal that may remain forever elusive. The disease of chronic pain should be considered, for some, from a more psychological perspective, which may lend insight into the root causes of a patient’s recurrent suffering and disability.

The goal of psychological management is not just to treat pain symptoms by targeting nociceptors of pain, but also to delve into the individual psychology of pain. This can be accomplished by teaching rehabilitation patients self-efficacy and independence through better pain management coping strategies. This process may not only enable pain sufferers to feel more in control of their lives, but also less dependent on medications and procedures.

Pain is experienced as an emotional as well as physical experience. Psychological therapy implies treatment of underlying mood disorders , which are commonly involved in chronic pain disorders. We know through functional MRI and other brain scanning tools that the perception of pain involves up to ten brain regions at once, which transmit information back and forth. Thereby, it is imperative to understand the role and principles of psychological management to attempt to address the “brain” part of pain.

The physiatrist, who sees a range of chronic, painful conditions, including devastating cases of musculoskeletal, brain, and spinal cord injury, already understands that the rehabilitation patient must be treated with a comprehensive multidisciplinary approach. An inpatient rehabilitation patient works with a team of providers, which may include a physical therapist, occupational therapist, speech therapist, social worker, and medical specialist. The job of the physiatrist is to oversee this team, with an ultimate goal of helping the patient to achieve both short- and long-term functional goals to maintain independence. A chronic pain patient should be addressed with a similar multidisciplinary team-based treatment paradigm. This team may involve the pain management specialist, medical provider, physical therapist, social worker, and, ideally, the pain psychologist.

There has been extensive research and interest in the field of psychological pain management , and progress has been made in understanding what works and what doesn’t to improve pain and mood. Before a discourse on the most well-known form of psychological treatment, cognitive behavioral therapy , or CBT, an historical background, is warranted. Beginning in the 1960s, Wilbert Fordyce pioneered the concept of pain, moving its management domain from a purely biomedical model to a biopsychosocial model. The biopsychosocial model involves operant conditioning, which involves an understanding that behavior is always affected by the environment in which it exists. That is, there is a reciprocal relationship between pain behaviors (i.e., hobbling, grimacing, groaning, contorting posture, activity avoidance) and the responses they elicit, the latter of which can either reinforce or blunt future behaviors. The result of this model was to draw the treatment focus away from the experience of pain sensation and instead towards achieving life goals and functional independence. In fact, Fordyce proposed that we systematically ignore pain behaviors and instead encourage well behaviors, such as activity tolerance and graded exercise.

In the CBT model , the provider must understand the crucial role he or she plays in helping to formulate a patient’s conceptions about pain. Christopher Eccleston, a prolific writer in the field of psychological approaches to pain management, stated, “Beliefs about the cause, meaning, and consequence of pain are often at stake in any consultation”. He enforced the notion that the treating physician is a powerful cocreator of a patient’s beliefs about pain. How the physician listens, empathizes, and reacts to a patient in pain can alternatively negate or reinforce a patient’s own behavior regarding pain. For instance, a patient who reports 10/10 pain intensity on the numeric rating scale (NRS) and displays dramatic pain behavior at a medical clinic is often treated with more potent drugs, sent for more tests at an urgent pace, and offered invasive treatments, including surgery, regardless of the underlying cause of pain. Such a response may validate a patient’s belief that his or her illness is overly dire to deserving of so much attention. This perception persists even if the working diagnosis is common and relatively benign. Similarly, family members of patients who display severe pain behaviors feel obliged to express sympathy, to excuse their loved ones from household responsibilities, and to encourage passivity or helplessness. Secondary gain isn’t necessarily the prime motivator of the sufferer, who may only seek empathy, understanding, and pain relief. However, overattention to chronic somatic pain symptoms without acknowledgement of social context can negatively reinforce pain behaviors, inactivity, and attention to nociceptive stimuli.

In cognitive behavioral therapy , there is an optimistic notion that people can learn more adaptive ways of thinking, feeling, and reacting to pain. Pain patients can become active collaborators in changing maladaptive beliefs and can thereby become more present, focused, active, and efficient managers of their own symptoms. CBT therapists are educators and coaches. Spouses and loved-ones can also become involved in the therapy, and can learn to react to the pain patient’s pain in ways that support function and coping, rather than passivity and helplessness. In the following paragraphs, particular psychological strategies are discussed.

In 1969, Neal Miller demonstrated that through biofeedback , it was possible to teach people to gain control over their autonomic peripheral nervous system and stress hormones, both of which may play a role in maintenance of pain and pain-related anxiety. Biofeedback is a useful psychological strategy, which is often used in combination with other therapies. It involves controlling pain through monitoring a patient’s peripheral physiological responses, including respiratory rate, breath quality, heart rate, blood pressure, skin temperature, and muscle tension. With biofeedback, the patient learns and practices self-regulation of these physiological variables. Neurophysiologist, Christopher deCharms, studied headache using EMG feedback to help patients decrease tension in their frontalis muscles and to thereby alleviate tension-type headache pain. In a contemporary example of biofeedback, functional MRI studies designed by Sean Mackey and deCharms have shown that patients can gain voluntary control over the activation of the rostral anterior cingulate cortex (involved in pain perception and regulation). Biofeedback can enhance the relaxation response and can also diminish muscle tension, both of which are both helpful in pain treatment .

Relaxation therapy is a psychological coping strategy that generally involves muscle relaxation and controlled breathing. There are a plethora of relaxation techniques, which involve various activities and senses, including meditation, aerobic exercise, imagery, sound therapy, water therapy, engagement in pleasurable activities, massage, tai chi, and yoga. Relaxation therapy involves invoking the relaxation response, which decreases stress hormones, improves brain function, and distracts attention away from pain. Because there is no one proven superior relaxation strategy, making use of one or many of the senses while individualizing treatment is most useful.

Hypnosis is another psychological tool that can be learned and applied to some pain patients. Although studies suffer from low enrollment and poor long-term follow-up, this strategy has been shown to be effective in small studies when compared to physical therapy and education alone. In hypnosis, there is a direct suggestion of anesthesia, called “glove anesthesia ,” which can lead to displacement of pain through physical dissociation. Hypnosis sessions usually run about 30 min, and involve a trained hypnotist who induces an altered state of consciousness in the patient. The patient is alert and awake, but distanced from the outer world and focused on inner thoughts and emotions through the therapist’s suggestions and guided imagery. Hypnosis has been shown to help with relaxation, sleep, and quality of life. Instruction in self-hypnosis and home practice is essential.

Mindfulness-based stress reduction , or MBSR, popularized by Jon Kabat-Zinn in 1979 and derived from Buddhist teachings, is a secular mind–body strategy involving the theoretical constructs of non-judgement, patience, the beginner’s mind, trust, non-striving, acceptance, letting go, and being in the moment. The goal is to uncouple the physical sensing of pain from the emotional suffering it causes. One practices to become desensitized to pain through acceptance of pain as a purely physical state. The practitioner of mindfulness therapy learns to regulate one’s emotions and reactions to pain. Instead of cognitively reconstructing “what” one thinks about pain, as in CBT strategies, the focus is on “how” one thinks about pain.

Cognitive coping models of psychological therapy involve teaching patients to become aware of their maladaptive thoughts and behaviors in relation to their pain. Cognitive models were formally developed in the 1970s–1980s, and advanced from the purely behavioral strategies used previously, including relaxation therapy and biofeedback, into a broader package; thus, cognitive behavioral therapy, or CBT, was born. Cognitive behavioral therapy involves a combination of stress management, problem-solving, goal setting, activity pacing, and self-efficacy techniques. There is an understanding that, similar to other chronic medical conditions including diabetes and hypertension, patients must learn to manage symptoms over extended periods of time.