by Renee Mill, Clinical Psychologist
Around one in five adult Australians – some four million people – suffer from chronic or persisting pain at any one time. The most common cause of this type of pain is degenerative conditions of the spine, but chronic pain is also a problem for patients with cancer, burns, migraines and autoimmune diseases such as arthritis, fibromyalgia, multiple sclerosis, and other conditions.
Chronic pain can impact on many areas of a patient’s life and is often associated with functional, psychological and social problems, as it affects not only the patient, but their family, employment, leisure activities and life goals.
As pain moves from the acute to the chronic stages, factors in the pain system other than tissue damage play a significant role. Gatchel’s (1996) three stage model illustrates how pain may progress from acute pain to chronic pain and disability. As pain persists over time, patients undergo significant psychological changes. In Stage 1, the patient’s perception of acute pain may result in normal emotional reactions including fear, anxiety and worry. If pain continues to persist, the patient may enter stage 2, in which behavioural and psychological reactions become more complex and the patient may experience depression, anxiety, anger and substance abuse. Gatchel hypothesized that if pain continues to persist beyond this stage, the patient may accept the “sick role” as his or her life begins to revolve around the pain.
The adoption of the “sick role” becomes problematic as it may lead the patient to arrange his or her life to avoid as much activity as possible in an attempt to lessen his or her pain. Reduced activity levels, long-term use of analgesics and sedatives for pain relief and repeated treatment failures may lead to physical deterioration, job loss, financial difficulties, family stress and feelings of depression, helplessness and irritability (Nicholas, Molloy, Tonkin and Beeston, 2005).
When pain becomes chronic, it is important that patients learn ways to manage it so they suffer less. Psychology-based treatment approaches assist patients in coping with their pain by reducing their levels of depression, anxiety and anger, improving their memory, concentration and self-esteem and helping them to feel a stronger sense of control over their lives. Pain management techniques aim to reduce the patient’s level of suffering and distress and to improve his or her quality of life, rather than to eliminate or cure pain.
A large number of randomised controlled trials support the effectiveness of Cognitive Behaviour (CBT) in the treatment of chronic pain (Sanders, 2003). Goal setting, activity scheduling and pacing, attention training and cognitive restructuring, which are the central intervention strategies of CBT-based interventions, are in line with the biopsychosocial model of chronic pain, which proposes that biological, psychological, and social factors interact dynamically with one another. CBT can be delivered individually or in a group setting.
Mindfulness has recently gained interest as a clinical intervention for chronic pain, with a number of small studies demonstrating medium to large sized effects on pain and general psychological symptoms. The mechanisms for this are not yet clear, but it is hypothesised that the skills that mindfulness cultivates such as self awareness, stability of mind, flexibility of awareness and non-reactivity, may assist patients in letting go of their unhelpful conditioned responses to pain (Walls, 2004).
When medical and surgical treatment have failed to alleviate a patient’s pain, referral to a Multidisciplinary Pain Management Program may be appropriate. The Australian Pain Society suggests that such programs are well suited to patients who over-rely on medication and therapies, experience significant depression or anxiety, lack effective coping skills and are receptive to the idea of adopting a self-management approach to their pain.
These programs generally adopt a Cognitive Behavioural approach to pain management and include a substantial educative component which teaches patients about concepts such as the scientific basis of chronic pain and pain pathways, the effects of pain medications and effective physical activity. Cognitive restructuring is taught to assist patients in understanding, identifying and challenging their maladaptive thoughts, beliefs and attitudes about their pain and patients are encouraged to make behavioural modifications such as goal-setting, communication skills, pacing and relaxation techniques.
Although management within a multidisciplinary setting is considered best practice for patients with chronic pain, some patients may not be suitable for such programs or may be more comfortable with one on one psychological therapy. The number of sessions required varies from person to person, but in general, pain management skills can be learned in as few as 12 sessions.
Gatchel, R.J. (1996). Psychological disorders and chronic pain: Cause-and-effect relationships. In R.J. Gatchel & D.C. Turk (Eds.),Psychological approaches to pain management: A practitioner's handbook. New York: Guilford Press.
Nicholas, M. K, Molloy, A, Tonkin, L, & Beeston, L. (2005). Manage your pain. Sydney: ABC Books.
Sanders, S.H. (2003). Operant therapy with pain patients: Evidence for its effectiveness. In A.H. Lebovits (Ed.), Seminars in pain medicine, 1, pp. 90–98. Philadelphia: W.B. Saunders.
Walls, S. (2004). Using Meditation Techniques to Manage Chronic Pain Mindfully. Wellbeing, 96, 52.