The biomedical model for approaching pain is being replaced with the biopsychosocial model. What role does psychology play in chronic pain prevention and treatment?
In 2011, the Institute of Medicine released a report stating that 100 million people in the United States are living with ongoing pain. (1) While the biomedical approach is often the default treatment plan used for pain care, these statistics suggest that it is not a sufficient enough solution. Since pharmaceutical drugs do not always resolve pain completely, a complementary and/or alternative approach is necessary. Given the reported impact of chronic pain on mental health, implementation of pain psychology into P.T. practice is becoming a more relevant and effective means of pain management. (2)
Just as there is no singular pharmacological solution for chronic pain, there are different approaches to pain treatment within the field of psychology. Five distinct psychological therapies for people with chronic pain have emerged, each demonstrating varying levels of success: these are Operant Behavioral Therapy, Cognitive-Behavioral Therapy, Mindfulness-Based Stress Reduction, Acceptance and Commitment Therapy, and Psychologically Informed Physical Therapy.Just as there is no single pharmacological response to treating chronic pain, there are also different approaches in the field of psychology Click To Tweet
Operant Behavioral Therapy (OBT)
The theory behind the Operant Behavioral model is that a person with chronic pain adapts to avoid the movements or behaviors that cause pain. (3) In the Operant Behavioral Therapy approach, treatment focuses on removing the negative associations with positive behaviors and adopting more positive responses to pain. A classic example of this is exposure treatment, whereby the fear or threat of pain is reduced by having the patient perform a behavior that elicits pain or unpleasant sensations, without a catastrophic outcome.
Cognitive-Behavioral Therapy (CBT)
The primary aim of CBT is to help patients develop positive coping mechanisms for dealing with their pain. A cognitive-behavioral therapist will also look at whether the patient has maladjusted beliefs or practices, such as “fear catastrophizing” (whereby a person fixates on an irrational or exaggeratedly negative thought or potential outcome). Dysfunctional thoughts are identified and replaced with more helpful ones, namely ones that support improved functioning and enhanced quality of life. CBT is currently considered the gold standard approach to psychological pain interventions, has the most RCT’s and meta-analysis to support its efficacy and has shown a consistent beneficial effect. (3)
Dr. Les Aria discusses the paradigm shift in pain psychology on the Healing Pain Podcast here.
Despite these benefits, misgivings with CBT led to further research and efforts in this field that have yielded two additional modalities: Mindfulness-Based Stress Reduction (MBSR) and Acceptance and Commitment Therapy (ACT).
Mindfulness-Based Stress Reduction (MBSR)
Unlike the CBT and OBT approaches, Mindfulness-Based Stress Reduction doesn’t seek to eliminate or even reduce pain. Its goal is to separate the experience of pain from its emotional or judgmental effects and to promote, instead, the patient’s detached awareness of their physiological experience. Using awareness practices and meditation tools, clients can learn to see the experience of pain as a discrete, temporary event. By becoming aware of the body; breath, physical sensation, and psychological reactions, sufferers of chronic pain can accept flare-ups without also experiencing undesirable emotional responses.
One example of formal MBSR might include seated meditation during a painful episode, without catastrophic consequence. MBSR often requires daily meditation practice, serving the additional purpose of increasing tolerance for negative emotions, thereby fostering adaptive response to pain. (3)
Practitioners do not prescribe specific goals, given the non-judgmental approach to treatment. (3) MBSR has been shown effective in various pain populations, including those with fibromyalgia, irritable bowel syndrome, and migraine. It has the additional benefit of addressing mental health concerns that are common in these populations, including depression and anxiety. MBSR also has a small movement component included in the treatment.
Acceptance and Commitment Therapy (ACT)
ACT is very similar to the mindfulness-based approach to pain care and management, as it does not seek to alter the presence of pain or the physiological pain experience. Instead, ACT practitioners help their patients to accept pain, identify unwanted beliefs and observe thoughts as passing phenomena. By accepting a painful “event,” thoughts and behaviors can be directed away from avoidance of pain and towards positive responses that are in line with predefined values. One of ACT’s greatest strengths lies in its ability to relieve distress, anxiety, and depression among chronic pain populations. (3, 4) You can read more about Acceptance and Commitment Therapy here!By accepting a painful “event,” thoughts and behaviors can be directed away from avoiding pain and more towards responses that are in line with predefined values and goals. Click To Tweet
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Psychologically Informed Physical Therapy (PIPT)
Cognitive and behavioral principles of pain psychology can be incorporated into conventional provider evaluation and treatment, as well as multidisciplinary pain care. Psychologically informed physical therapy is one way to address physical and psychosocial factors of pain care. (5) These include cognitive-behavioral techniques such as relaxation training, cognitive restructuring for catastrophizing and fear-avoidance behaviors, sleep education, coping skills, activity planning, and pleasant activities. Physical therapists are now expected to recognize pain that is associated with psychosocial distress (yellow flags) and to modify their treatment approach accordingly.
Heeding the National Call to Action
Physical therapists and other pain practitioners are embracing the psychosocial component of patient care. Pain management does not exclude emotional experience, “thereby establishing psychology as integral to the experience of both acute and chronic pain.” (6) More recently, data acquired through the National Pain Strategy revealed the need for better pain science training among healthcare clinicians and, specifically, through pain psychology. This data is a national call to action that can be heeded through improved understanding of pain science and a collaborative integration of pain psychology.
How do you address psychological concerns in your practice? How might we respond to the National Pain Strategy’s call for improved pain science and psychologically informed pain care? Share your thoughts and experiences with us on Facebook!It is a national call to action that has been heard and can be heeded through improved understanding of pain science and a collaborative integration of pain psychology. Click To Tweet
[Read more about pain care at: 3 Key Skills of Psychologically Informed Pain Care]
- IOM Committee on Advancing Pain Research Care. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine. Washington (DC): National Academies Press; 2011.
- Darnall BD, Scheman J, Davin S, et al. Pain psychology: a global needs assessment and national call to action. Pain Medicine 2016;17:250-63.
- Sturgeon JA. Psychological therapies for the management of chronic pain. Psychology Research and Behavior Management 2014;7:115-24.
- Veehof MM, Oskam MJ, Schreurs KM, et al. Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain 2011;152(3):533-42.
- Keef FJ, Main CJ, George SZ. Advancing psychologically informed practice for patients with persistent muskuloskeletal pain: promise, pitfalls, and solutions. Phys Ther 2018;98(5):398-407.
- IASP Task Force on Taxonomy. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. Seattle: IASP Press; 1994.