(Talk) Therapy for Chronic Pain, Part 1
By Laura Meli, PhD
When someone experiences ongoing emotional pain, they may consider going to therapy to support their mental health. When someone feels ongoing physical pain, however, it’s far less common to consider talk therapy as a way to ease suffering or improve well-being. Typically, physical pain is thought of as strictly a physical health problem, best treated with a medical intervention of some kind. In many cases, this is true! You wouldn’t schedule a session with your therapist to treat a broken arm, right? Then why is therapy recommended as a treatment for those suffering with chronic pain?
This blog reflects a three-part series on chronic pain and mental health where I’ll explain how chronic pain impacts the brain and body, discuss the power of thought and self-understanding in managing chronic pain and improving well-being, and share ways you can support mind-body healing to reduce chronic pain symptoms and manage flares. First, let’s step back to better understand the different types of pain and understand how chronic pain connects to our emotional well-being.
Sounding the alarm: Why do we feel pain?
Everyone experiences physical pain from time to time. Sipping your morning coffee when it’s still too hot, hitting your funny bone on the door frame, waking up with aching muscles the day after a new workout - these experiences of pain are familiar and transient, causing temporary discomfort but not raising cause for concern. You experience the sensation of pain, react to the sensation with a wince or groan, and move along. The response to pain is often so automatic that it can make one consider - besides being a nuisance, what’s the point of pain anyway?
Pain is a lot like an alarm system for our body (and mind… more on that later!), with the ultimate goal of keeping you safe from harm. There’s a reason pain isn’t subtle - it’s an effective attention grabber because your body is trying to tell you something important and time sensitive. For instance, when you burn your tongue on that piping hot cup of joe, you almost immediately experience a highly aversive sensation and stop sipping to avoid burning your tongue. Simple and effective, right? Behind the scenes, however, things are much more complicated. Your body and brain are speeding through a well-choreographed dance to keep you safe. Nerves on your tongue notice a threat from the high temperature, pass along a warning through neuronal pathways traveling through your nervous system and brain, ultimately producing a painful sensation in your mouth, sparking the thought, “Ouch! Too hot!” and almost instinctively prompting you to put your mug down. All in an instant, your physiological internal alarm system reliably blares, encouraging feelings, thoughts, and behaviors to keep you safe from starting your day with a painful burnt tongue.
While it may not be pleasant, we need these moments of acute pain. Pain plays a vital role in keeping you safe and is ultimately necessary for survival. Considering its function, pain is actually an excellent messenger, deterrent, and teacher! Pain’s hard-to-ignore sensory messages are so powerful that they trigger automatic reflexes to help you avoid potential threats or dangers. Just because pain can be helpful certainly doesn’t mean you have to like it. Most everyone who experiences pain wants it to be gone – and fast! When physical pain continues or recurs for long periods of time, becoming chronic, it can be very challenging and even disheartening to endure. After all, pain is meant to be short-term warning bell and not a long-term or ongoing experience.
So, what happens when the body’s alarm system won’t stop ringing? What happens when pain drags on long after an imminent threat has resolved or if there is no threat?
What is chronic pain?
Chronic pain is defined as physical pain that lasts three or more months past the point when an injury has healed or that occurs in the absence of a clear physical source. In other words, chronic pain is a condition where our body’s alarm system malfunctions – continuing to sense danger and send pain signals to the brain. Over time, prolonged pain signaling can lead to changes in the mind-body connection, making the treatment of chronic pain require more than just medical care for pain management.
There are three main types of chronic pain that people experience: nociceptive pain, neuropathic pain, and neuroplastic pain. Nociceptive pain stems from conditions and injuries to the body’s tissue and can include migraines, arthritis, musculoskeletal conditions, and more. Neuropathic pain comes from nerve damage or damage to the nervous system, itself; neuropathic pain includes conditions like sciatica, pain from multiple sclerosis, and neuropathies. Neuroplastic pain is, in many ways, the most misunderstood form of chronic pain and includes conditions like fibromyalgia, irritable bowel syndrome, and pelvic pain syndrome, among others. Neuroplastic pain sometimes begins with a tissue injury or nerve damage, but then persists even after the physical injury resolves. Other times, there is no evidence of a physical source of symptoms causing the pain. By nature, neuroplastic chronic pain strongly relates to the mind-body connection because it is defined by changes to the way pain is perceived and processed. This can make neuroplastic pain particularly hard to diagnose, treat, understand, and explain.
While there are certainly many unknowns when discussing chronic pain, one fact is abundantly clear - chronic pain is very common and affects many people. Chronic pain impacts over 50 million adults in the United States – that’s approximately 1 out of every 5 people (CDC, 2023). Of these individuals, 10% experience high-impact chronic pain that it limits the ability to live life the way they want to or do things that bring them satisfaction. That’s almost 20 million adults experiencing significant physical suffering on a daily basis to the point that they have difficulty maintaining hobbies, interpersonal relationships, family obligations, school and work performance, and basic self-care tasks. Despite high prevalence rates and the undeniable burden individuals with chronic pain conditions must manage, chronic pain is often dismissed and undertreated.
How does chronic pain work and can talk therapy actually help?
We often think of health from a dualistic perspective and treat the body and mind as separate – we see medical doctors for our bodies and mental health providers for our feelings. In reality, however, the mind and body are connected, meaning many physical health conditions have distinct psychological and emotional components. When it comes to pain specifically, research on the mind-body connection has even shown that our brains process physical pain and emotional pain similarly (Sturgeon & Zautra, 2016). Further, pain is highly subjective, meaning everyone’s experience of pain is slightly different and impacted by a multitude of factors. The way we perceive pain naturally changes throughout our life course and pain severity doesn’t always relate to injury severity (Gagliese, 2009; Gatchel, Peng, Peters, Fuchs, & Turk, 2007). In order to understand and treat pain, it’s important to look beyond the physical.
Chronic pain is a unique type of pain that is widely recognized as more than just a physical condition. In fact, it’s best understood as multidimensional, meaning it has physical, psychological, emotional, and social components all at once. Because of its complexity, chronic pain can bring stress to and demand change in nearly all parts of an individual’s life – straining relationships, complicating routines, and limiting physical abilities. Therapy for chronic pain is an important and effective treatment option to address the emotional symptoms and psychological components of chronic pain conditions and to support well-being for individuals living with chronic pain.
An invisible illness
Chronic pain is considered an “invisible illness,” or an illness that isn’t immediately noticeable to others. Being “invisible” makes chronic pain more likely to be overlooked or questioned – leaving an additional burden on the patient to consider the pros and cons of disclosure, reckon with feelings of isolation, and bolster against the invalidating reactions of others. Many people living with chronic pain are all too familiar with feeling dismissed, questioned, or having to prove their pain is “real.” Of course, just because chronic pain isn’t “visible” to the naked eye or may not be “verifiable” on medical scans, the suffering it causes is no less real or valid. Unfortunately for people living with chronic pain, however, the question of validity often enters the conversation – with family, friends, employers, and even (or perhaps, especially) doctors.
Medical settings can be especially tricky for individuals with chronic pain and the path toward diagnosis, treatment, and symptom relief is rarely straightforward. Many chronic pain sufferers know the experience of being bounced from specialist to specialist, told time and time again by providers that their pain is “all in their head” or “can’t be that bad,” or had their suffering dismissed and labeled as “just anxiety or depression.” These experiences and messages can have a profound and lasting impact on a person’s sense of self-trust, confidence, relationships, and mental health. When medical professionals, clinical providers, and social supports deny experiences of chronic pain, they unintentionally exacerbate feelings of self-doubt and invalidation for patients. Not only can invalidation actually worsen pain symptoms and contribute to depression and anxiety, but these experiences also drive many chronic pain patients away from medical settings, altogether, reinforcing messages that their suffering isn’t real, they are better off managing alone, or there’s no hope for feeling better.
While there is a diversity of experiences when it comes to chronic pain, those with continual experiences of invalidation around their symptoms may also struggle with self-trust. Over time, prejudicial attitudes and internalized ableism, or the belief or being “less than” due to an individual’s limitation or disability, can emerge. Internalized ableism often results in chronic pain sufferers attempt to minimize or ignore their symptoms in an attempt to present as though nothing is wrong. These attempts at hiding, or masking, symptoms can increase pain, worsen fatigue, and ultimately negatively impact mental health. Increasing awareness around invalidating behaviors and processing experiences of invalidation is essential in challenging the negative effects of ableism and internalized ableism for chronic pain sufferers.
Tips and resources for chronic pain
Chronic pain is a real and significant life stressor, just as deserving of care and compassion as any other source of suffering. If you or someone you know is living with chronic pain, here are some tips and resources that may be helpful:
1. Check out websites that affirm and normalize the challenges of living with chronic pain.
2. Consider therapy for chronic pain.
Bring up your experiences of pain in therapy! Chronic pain is a stressful condition and higher stress can make pain worse. Of course, stress is an unavoidable part of life, but being mindful of your stress levels, noticing patterns in the ways you respond to stress and pain, and learning new ways to manage your symptoms can help.
3. Stay connected.
Living with chronic pain can mean navigating feelings of isolation, particularly when pain disrupts social plans, impacts physical abilities, or begins leading to depression or anxiety symptoms. Further, isolation and loneliness themselves are risk factors for worse physical and mental health. While it may not always feel easy, staying in touch with friends, family, or even community groups is a powerful way to help manage your chronic pain and support your mental health.
4. Build a validating inner circle.
For many reasons, chronic pain can be hard on self-trust and lead to self-criticism. Find a friend or family member, peer group, blog, social media account, or organization that understands chronic pain and turn to them for validation and support of your experience. It can even be helpful to bring a supportive figure to doctor’s appointments and procedures!
5. Find a pain specialist.
Finding doctors who are familiar with or, ideally, specialize in chronic pain is essential in helping to figure out the most effective pain management plan. This isn’t always easy to do, but it is important to have a care team that understands your unique experience and needs. If you’re not sure where to start, try asking your primary care doctor for referrals, discussing your concerns with a therapist, or using the search tools available in the resources above.
About the Author: Dr. Meli is a postdoctoral fellow at Manhattan Therapy Collective. She knows, firsthand, the realities of life with chronic pain and loves empowering others through increasing knowledge about the mind-body connection.
References:
Cohen, S. P., Vase, L., & Hooten, W. M. (2021). Chronic pain: an update on burden, best practices, and new advances. The Lancet, 397(10289), 2082-2097.
Gagliese, L. (2009). Pain and aging: the emergence of a new subfield of pain research. The Journal of Pain, 10(4), 343-353.
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.
Rikard S.M., Strahan A.E., Schmit K.M., Guy G.P. (2023). Chronic Pain Among Adults — United States, 2019–2021. Morb Mortal Wkly Rep, 72: 379–385.
Sturgeon, J. A., & Zautra, A. J. (2016). Social pain and physical pain: shared paths to resilience. Pain Management, 6(1), 63-74.