I Have Chronic Pain, Why Do I Need a Pain Psychologist?

"Why am I seeing you? I’m not crazy, I’m in pain!" I hear these words several times a week from patients that have been referred to me for treatment, assessment, or consultation concerning chronic pain. During the first session with new patients I assure them that they are not crazy, but, in fact, very lucky to have a physician that recognizes the many facets of chronic pain. Psychologists are generally part of the treatment team for patients suffering from chronic pain (including cancer pain) as well as other chronic conditions. The psychologist may actually reside in the physicians office, or have a private office that the physician referrers to, or both!

This type of treatment model, where a psychologist is involved, is relatively new to western medicine. Psychological treatment was actually considered an alternative treatment not too long ago. As we moved away from Descartes’ model of duality, where the mind and body are separate to more of a holistic understanding of the patient, we began to understand that there is a mind-body connection. Today we realize that there is even more to this; there is actually a mind-body and body-mind connection representing that communication is two-way. Having this knowledge has enabled us to realize that something was missing in our treatment of chronic pain patients, namely a holistic conceptualization of our patients.

In 1979, The International Association for the Study of Pain (IASP) officially redefined pain as "an unpleasant sensory and emotional experience, associated with actual or potential damage or described in terms of such damage." This definition not only recognizes that pain involves thoughts and feelings, but also that pain is real whether or not the biological "causes" are known. The idea that pain is a subjective and highly personal experience was also neatly expressed by McCafferey who defined pain as "whatever the experiencing person says it is, whenever the experiencing person says it does." These definitions reflect the realization that pain is a subjective experience involving all sensory modalities.

Recent research suggests that pain is mismanaged in up to 50% of cases. Many of the reasons for the mismanagement of pain are psychological. For example, irrational fears about addiction, underreporting of pain, inadequate communication between patient and doctor, lack of knowledge, etc. A skilled pain psychologist is best able to identify blocking beliefs, fears, etc that may contribute to the mismanagement of pain. This information can be invaluable to other treatment professionals.

How can anyone with a significant degree of chronic pain only be affected physically? Pain makes you feel tired, mentally fuddled, irritable and often depressed. It affects you mentally and emotionally as well as physically. Many of the effects come into play quite quickly. If a family member changes from relaxed and easy-going, to irritable and worried by continued pain, how many weeks will pass before family relationships begin to change? Similarly, an employer who had confidence in a promising employee does not take too long to change his or her attitude to one who constantly looks tired and strained.

It is because of these effects of pain on individuals that psychology has a part to play. Psychologists working in chronic pain are not trying to see whether pain is real or imaginary. All pain is real to the sufferer. Pain doesn't just affect the body. It also affects how much you can do, how you feel emotionally, the quality of your life and those around you. There may be many losses as a result of pain, e.g. job, finances, self-esteem and confidence. Thinking patterns can change, become negative, low and full of frustration. Tempers can become short and memory and concentration poor as a result of long term pain, all of which can affect mood.

Pain psychologists can help with these problems by using psychology-based treatment approaches which reverse some of the effects of the pain and help people feel more sense of control, reduce depression and anxiety, and improve memory, concentration and self-esteem. Their aim is to help people work out ways to live as normal a life as possible despite the pain.

You may be referred to a pain psychologist for many reasons, some of which I have touched on above. Other reasons for the referral may be to see if you are a candidate for certain therapies including high dose opiods, intrathecal infusion pumps, spinal cord stimulators, and surgeries, such as fusions, laminectomies, etc. Your physician may also want to see if you would be a good candidate for a behavioral chronic pain program or a work hardening program. Because the subjective experience of pain may occur in the absence of demonstrable tissue damage, as I mentioned earlier, it is not a purely physical phenomenon, but has highly significant psychological components. The complex interaction of cognitive, behavioral, emotional and physiological factors is a vital component in determining the individual’s experience of pain. The pain experience, therefore, will be different from person to person as a result of varying combinations of these factors. This of course is why a psychological assessment, focusing on the biopsychosocial aspects of the patient’s pain, is crucial before any type of intervention is begun.

The assessment of the psychosocial aspects of an individual’s persistent pain involves and requires the accurate evaluation of:

• Behavioral changes in various areas: work, domestic responsibilities, leisure and recreation activities, social, marital, partner and/or family roles, sleep disturbance, frequency of sexual relations, and medication use.

• Cognitive factors, including beliefs and attitudes, expectations, coping skills and pre-existing personality factors.

• Emotional state (such as the presence and severity of anxiety and depression).

• Assessment of predisposing factors such as a history of childhood hospitalization, sickness model of significant others, or a history of emotional, physical or sexual abuse

• Role of post traumatic stress disorder symptoms in maintaining physiological arousal that may impact on the perception of pain. This may be pre-existing or may arise from the incident causing the pain.

• Learning factors to be considered include the reinforcement of sick role or illness behaviors or the avoidance of unpleasant activities by the use of pain and illness behavior. Precipitating factors which also need to be evaluated include work difficulties, marital and family problems, the death of a family member, or other significant loss prior to the onset of pain. Assessment of additional factors such as litigation or financial difficulties is also important.

After an evaluation your pain psychologist might recommend several types of treatment including:

• Individual psychotherapy to help you better understand your own behavioral and emotional responses to the pain and help you modify those responses in ways that increase your comfort, ability to cope, and sense of well being.

• Pain management group to help you learn sufficient self management strategies for your pain.

• Biofeedback to help you learn to reduce activity of the part of your nervous system that responds to stress. Activity from this part of the nervous system increases pain.

• Retraining chronic bracing and guarding muscle tension patterns that have developed because of your pain, but which with time feed back into the pain making it worse.

• Pain Management Program that is multidisciplinary (i.e. psychologist, chiropractor or physical therapist, pain physician) and aims at decreasing psychological distress and increasing functional capabilities. The program should include, among others, the following interventions: group psychotherapy, relaxation training, physical fitness and conditioning exercises, and medication management.

When the pain psychologist is performing an assessment for intrathecal infusion pumps, spinal cord stimulators, or surgeries (e.g. fusion, laminectomy) they will evaluate the patient based on the data from the assessment to try and determine specific psychological risk factors for chronic disability that may be barriers to recovery following the sugery or implantation. The pain psychologist may make a recommendation that the patient receive pre-surgical counseling or psychotherapy for a premorbid psychological condition before surgery or implantation. The pain psychologist’s goal is to help you have the best oucome you can possibly have from your procedure.

It is important when choosing a pain psychologist or any provider for that matter, that you be aware of their training. It is my recommendation that your pain psychologist has had supervised training and experience in the assessment and treatment of patients with persistent pain. Pain psychologists usually, but not always, have a health psychology background with a speciality in pain management. These types of psycologists can provide a variety of treament to different populations as a generalist, but also as a specialist in pain.

Pain does not happen in a vacuum; it happens in a human being with a personality, likes and dislikes, strengths and weaknesses, and ways of thinking. Chronic pain complicates people's lives, diminishes their emotional and physical capabilities, questions their coping strategies, and fatigues them and their family and friends. Chronic pain often adds stress that breaks down relationships with family and friends, leaving a person isolated and alone and feeling no one understands them or their pain. Depression, anger, and anxiety often result from chronic pain. A pain psychologist has studied pain and its effect on human functioning. He or she can help you with effective strategies and skills to increase your ability to cope with your pain. A pain psychologist can treat your depression and anxiety and help you to separate it from the pain so you no longer have the emotional "roller coaster" rides as your pain intensity varies. So when your physician refers you to a pain psychologist, realize how much he or she is invested in you getting holistic treatment.