Therapy for Chronic Pain, Part 2: What Affects Your Pain?
By Laura Meli, PhD
In Part 1 of this series on talk therapy for chronic pain, we learned that physical pain is like our body’s protective alarm system, supporting safety and survival. We also began exploring the ways chronic pain connects not only to our physical well-being but also – importantly – to our emotional well-being.
Emerging science on the psychology of pain supports chronic pain psychotherapy as an effective treatment option. CBT for Chronic Pain (CBT-CP) and Pain Reprocessing Therapy (PRT) are two evidence-based approaches that can help to reduce pain and improve well-being by targeting thoughts patterns, emotion regulation, and beliefs about pain. Here, in Part 2, we’ll discuss how exactly our thoughts and beliefs influence pain. I’ll also share some tips for how to harness the power of your thoughts to help manage chronic pain and start feeling better.
Before we jump in, I want to provide a friendly reminder that it is important to involve a medical professional in your care if you are experiencing chronic pain, or any other concerning symptoms. As many individuals living with chronic pain will know, medical care alone doesn’t always offer relief or a long-term solution. However, a professional medical evaluation can give you an up to date picture of your pain or symptoms as you consider psychotherapeutic treatment options.
False alarm, real pain: What is neuroplastic pain
We already know that pain is an important alarm system to help us avoid or reduce injury. In the broad scheme of things, pain does a good job keeping us safe (thanks, pain!). Like any alarm system, false alarms can occur. If you set off the smoke alarm from a burnt batch of cookies, the blaring noise of a false alarm is very real, very surprising, and very annoying. Despite a pair of ringing ears, though, there isn’t actually any danger – just a signal. When our pain system has a false alarm, activating pain signals in the absence of a physical injury or tissue damage, it is called neuroplastic pain. Rather than being generated from a physical injury, neuroplastic pain is generated from signals in the brain. This means that you can feel real, debilitating pain, with or without a physical source.
Neuroplastic pain is normal and common. Even if you’ve never experienced chronic pain, you have probably still experienced neuroplastic pain. Have you ever jumped into water so cold that it stung? You’re not actually cold enough to risk frostbite; your brain is generating neuroplastic pain – pain signals without injury. You unconsciously interpret the abrupt temperature change as dangerous, sending you a loud physical sensation as an alert. Because you know there’s nothing to fear, the pain slowly subsides and simply becomes a sensation – a cool, refreshing swim.
Most chronic pain involves neuroplastic pain, which means that most chronic pain doesn’t actually stem from physical damage. Instead, the pain is generated from ongoing, faulty pain signaling in the nervous system and brain. Since the pain isn’t coming from a physical source, there isn’t a physical solution. In order to influence chronic pain, we need to take a closer look at our thoughts.
How does fear affect pain: Fact-checking fear
Since pain’s job is to alert us to danger, it’s no wonder pain is often associated with feelings of fear and distress. Fear is our emotional response to thoughts of danger, and pain is our physical response. If pain were a math equation, we could say Sensation + Fear = Pain. Fear fuels pain. Without a sense of fear or danger, pain simply becomes a physical sensation. When left unchecked, fear and pain can become a vicious cycle maintaining chronic pain. When we anticipate or fear pain, it reinforces the message that the sensation is dangerous and must be monitored constantly. Fear keeps our brain and nervous system on high-alert, increasing our perceptions of pain. Over time, the pain-fear cycle of chronic pain can rewire and sensitize our nervous system to keep the pain dial turned up, leading to more stress, anxiety, fear, worry, and of course, more pain.
Much of pain processing happens automatically and unconsciously, in our brain and nervous system. How can we disrupt this pain-fear cycle if it’s part of our biology? We can actually challenge the fear-based thoughts in our awareness to influence the chronic pain process. Remember - less fear, less pain. Taking a closer look at your beliefs about pain can be a helpful place to start. Here are some questions to help you get started: When you start to feel pain, what goes through your mind? What are your usual responses to pain? What worst-case scenarios go through your mind when you’re in pain? Do you have any strong or rigid beliefs about your pain? By considering the ways that you understand and think about pain, you can better understand how fear plays a part in your unique, individual pain-fear cycle. Once you know what worries you, you can begin to fact-check your fears about pain - on your own, or with a therapist or doctor.
What is gate control theory: Opening and closing the door on pain
For more than 60 years, science has been aware of a specialized “pain gate” in the spinal cord. When the pain gate opens, pain intensity worsens. When it closes its doors, pain intensity improves. What makes this gate open and close? It’s complicated. Pain is processed in about 44 different regions of the brain, meaning there isn’t just one way to influence the pain gate. In fact, pain shares processing space with many brain regions including areas that control sensation, motivation, memory, attention, thoughts, and feelings. Because pain shares real estate with so many important brain functions and travels through many common neural pathways, there are actually lots of ways to influence the pain gate! Think about the implications of this “pain gate,” for a moment… We often think pain is some uncontrollable physical process we are sentenced to, but the pain gate proves that pain is somewhat within our control. Changing your behaviors, emotions, and thoughts can all change your pain – opening or closing the pain gate, increasing or decreasing pain levels.
Let’s take a quick look at three different factors that are known to open or close the pain gate - namely, physical, emotional, and cognitive factors that can increase or decrease pain.
Physical factors
Open the gate (increase pain)
Being injured
Being sick or having an infection
Poor or inadequate sleep
Close the gate (decrease pain)
Getting enough sleep
Eating a healthy, balanced diet
Emotional factors
Open the gate (increase pain)
High stress levels
Fear, anxiety, or anticipation
Close the gate (decrease pain)
Emotion regulation skills
Enjoyable emotions (happiness, safety, hopefulness)
Cognitive factors
Open the gate (increase pain)
Self-critical thinking
Rumination or “thought spirals”
Helplessness
Close the gate (decrease pain)
Self-compassionate thinking
Mindfulness (being present and non-judgmental)
Two personalized strategies that can close your pain gate
Strategy #1 - Take a (mental) vacation.
People living with chronic pain understand the phrase “I need a vacation” more deeply than most. Ironically, it can also feel very hard to take a break from chronic pain because we all live in our bodies 24/7 – no matter how they feel. So – how in the world can you take a vacation from your own body? Try a mental vacation! Create a comfortable and peaceful environment for yourself, close your eyes if you’d like, let your breathing become slower and deeper, and bring to mind your dream vacation spot. Let your mind wander, noticing every detail and tuning into each one of your senses – the warm sun on your face, the refreshing ocean mist and salty seaside air, the rhythmic sound of gentle waves, the endless-seeming horizon… If it feels hard to muster up a vacation in your mind’s eye, you can look through old photos, search online for beautiful destination pictures, or even check out YouTube for videos to help curate your dream mental vacation. You might be asking yourself, “this sounds pleasant enough, but what does it have to do with my pain?” I’m glad you asked! Staying present in activities, focusing on positive emotions and thoughts, and practicing flexible thinking (aka practicing turning your attention where you want it) all reduce pain intensity. Research also backs distraction and taking mental breaks as effective strategies for managing distress. By taking a break and focusing completely (with all five senses) on something enjoyable, you can regulate your emotions and feel energized to return to your day. Practice taking a mental vacation when you feel overwhelmed by frustrating or anxious thoughts from chronic pain.
Strategy #2 – Kindness counts.
Chronic pain can make it difficult to feel happy or hopeful. Let’s face it – it can be hard to “look on the bright side” when you’re hurting… all the time. So, are you destined to be in pain and fake a smile? No way! Rather than force a positive mood, you can feel better and reduce your pain through your thoughts. When we’re down or in pain, we tend to think self-critically, ignoring the neutral or positive parts of ourselves. We might blame our bodies for the discomfort we feel or speak harshly to ourselves about our pain-related limitations. Self-criticism is a way of trying to snap ourselves out of it – kind of like a “tough love” act. Unfortunately, self-criticism only makes a bad mood worse and can open the pain gate, increasing pain. On the flip side, however, self-compassionate thinking can improve your mood and close the pain gate, decreasing pain. Simply being kind to yourself is actually good for your health! When you’re feeling down due to chronic pain, remember that kindness counts. Try writing down or saying aloud three self-compassionate statements and three positive or kind things about your body when you’re feeling down or self-critical due to chronic pain.
About the Author: Dr. Meli is a postdoctoral fellow at Manhattan Therapy Collective. She loves helping demystify the medical model with patients, empowering them to understand, experience, and trust their bodies and minds. Her favorite way to close the pain gate on her migraines this holiday season is perfecting her cinnamon roll recipe - allowing the comforting smells and delicious tastes to feel like a cozy, festive, mental vacation.