By Karen Baar, published on March 1, 2008 - last reviewed on July 23, 2013
Pain is typically the sign of a broken body part. But often it has a life of its own—flaring up when you least expect it, spreading to other areas, and even persisting once the offending source is fully healed. In the end, it's in your head. Which means pain can play mind games with you—but also that you can fight back once you know its tricks.
Cognitive behavioral therapy (CBT) is one of several arrows in your quiver that can help you outsmart persistent pain. Researchers have dramatically shown that CBT can be as effective in treating chronic low back pain as lumbar spinal fusion, a major surgical procedure.
"Changing the way a person thinks about and interprets pain can alter the experience of pain," says Benson Hoffman, a clinical associate at Duke University Medical Center. Hoffman coauthored a recent meta-analysis showing that CBT, behavioral therapies, and self-regulatory therapies (biofeedback, hypnosis, and relaxation training) were highly effective in treating people with chronic low back pain. "I expected that these therapies would help people cope with pain, return to work, maybe reduce depression," he says. "What surprised me was that the greatest impact was on pain intensity." These treatments don't just help you deal with the physical discomfort, they actually reduce it.
The use of psychological treatments reflects a shift away from the medical model of pain, which construes pain narrowly—as a sensory event directly arising from disease or tissue damage.
"The idea was that when we experience pain we experience it at a specific site and it is an indication that something is wrong," says Robert Kerns, a psychiatry professor at Yale. Beginning in the mid-1960s, an evolving understanding led to the so-called biopsychosocial model of pain, which sees pain not only as a sensory event but also as an emotional experience, one shaped by our thoughts and beliefs about the causes and consequences of the pain, as well as by our reactions to stress and our social world.
Emotional arousal can influence pain directly by increasing muscle tension and altering levels of hormones and neurotransmitters associated with pain. It may also have an indirect impact. Fear of re-injury or more pain, for example, can lead us to limit or avoid activities, which then decreases muscle strength and causes loss of function and more pain and disability.
Those in pain often feel angry, frightened, helpless, resentful, depressed, or guilty about being a burden, and they may try to bottle it up to ease others' discomfort. But suffering is a social experience. Partners and loved ones also experience intense feelings—they have to watch someone they care about in distress—and they too tend to hold in their feelings of sadness, anxiety, or inadequacy.
When the patient, the partner, or, especially, both shy from emotional expression, the silence can make the pain worse. In one study at Duke, patients with osteoarthritis and gastrointestinal cancer who bottled up their emotions were much more likely to dwell on and exaggerate the meaning of their pain, which exacerbates pain intensity.
Frank Keefe of Duke's Pain Prevention and Treatment Research Program and other researchers are studying the intricate dance between people in pain and their loved ones. They aim to develop interventions that reduce ambivalence about expression and better allow both patients and their partners to communicate not only if and when they are in pain, but also how they feel about it.
Researchers are still working to pinpoint which patients will benefit from a particular intervention or combination of approaches. "There's nothing special about any specific technique," explains Dennis Turk, a professor of anesthesiology and pain research at the University of Washington. CBT and the other methods "are all designed to bring about the same endpoint: helping a person self-manage their condition." He wants them to take an active role rather than play the fatalistic victim.
Keefe says the most important stage of recovery is making the decision to try something new. "When someone is skeptical that relaxation will help their pain, I tell them, 'Don't take my word for it—let's approach each technique as a mini-experiment.' If they take that first step, they can do quite well."
Indeed, when Penny Cowan entered a residential pain management program at the Cleveland Clinic, she expected to fail. Suffering from fibromyalgia, she experienced so much pain that she had tried to convince her husband to leave and take their two children with him. "I didn't have any hope. In fact, I wanted to show the doctor that nothing would work. But I left home as a patient and came back as a person." She was so relieved that she founded the American Chronic Pain Association to help others learn and maintain the skills that helped her finally manage her pain.
Combining conventional medical treatment with a psychological approach may be your best bet. With an orchestrated effort, you can keep pain from getting the upper hand. According to Tracey Libby, a psychotherapist who has dealt with her own chronic pain, "We're still people; we need to enjoy our lives. We aren't our pain." —Karen Baar
Consider these complements to a conventional medical approach.