Psychologically Informed Approaches to Pain

5 solutions for living your best life.

Posted Dec 17, 2019

Joe Tatta
Psychologically Informed Pain Care
Source: Joe Tatta

The effective and safe treatment of chronic pain is on everyone's radar. 

The opioid epidemic, poorly covered pain treatment, and a lack of information are a triple threat for those living with chronic pain. Even practitioners, healthcare systems, and insurers are scrambling to find safe and effective ways to treat, manage, and reverse chronic pain. 

Where do people who are suffering turn for safe and effective treatments to live a healthier life with less pain?

As global healthcare systems pivot toward a comprehensive (biopsychosocial) approach for pain, the spotlight is shining on psychological interventions. Cognitive and behavioral treatments have a long history of helping people cope with pain, and are supported by rigorous scientific testing.

Just as there is no single pharmacologic silver bullet for chronic pain, different psychological approaches for the treatment of pain have blossomed from the rich fields of psychology, physical therapy, and others. Five distinct cognitive-behavioral interventions are leading the pack and easing pain with safe, effective, and long-term solutions. 

5 Psychologically Informed Approaches to Pain

#1: Cognitive-Behavioral Therapy (CBT)

The grand poobah of psychological treatments for pain is cognitive-behavioral therapy (CBT). The primary aim of CBT is to help patients develop positive coping mechanisms for dealing with pain. A cognitive-behavioral approach targets distorted thoughts and pain beliefs and how they influence behavior. Dysfunctional thoughts are identified, challenged, and replaced with more helpful ones to support improved functioning and enhanced quality of life.

CBT is currently considered the gold-standard approach and has a deep history of randomized controlled trials and meta-analyses that consistently demonstrate positive outcomes. Traditional CBT protocols for pain may include:

  • Relaxation training
  • Activity pacing
  • Graded activity
  • Graded exposure
  • Cognitive coping techniques
  • Foundational instruction on sleep 
  • Foundational education on nutrition

The primary theoretical mechanism of action in CBT is proposed to be cognitive change, which is expected to lead to improvements in other symptoms via cascading effects. The most immediate focus of CBT is on symptom reduction—although improved functioning is also a long-term goal of treatment. 

#2: Acceptance and Commitment Therapy (ACT)

Moving toward unpleasant sensations in the service of deeply held personal values may just be the way to move beyond pain. Acceptance and Commitment Therapy (ACT) is fast becoming a crowd favorite in many pain rehabilitation programs.

Riding high on the third wave of cognitive-behavioral therapies, ACT uses acceptance, mindfulness, commitment, and behavior change strategies to increase psychological flexibility. While traditional CBT zooms in on modifying distorted cognitions and beliefs, ACT works more through the modification of behavioral avoidance patterns rather than changing distorted cognitions.

ACT has two major goals. The first is to foster acceptance of unwanted private experiences that are out of one's personal control, and the second is to facilitate commitment and action towards living a valued life. Acceptance is promoted instead of changing one's inner experiences, clarifying personal values are used as a basis for motivating behavior, and cognitive defusion is employed versus cognitive restructuring. 

  • Accept all sensations and be present
  • Choose valued directions
  • Take action

With over 300 randomized controlled trials for mental and physical health conditions, and at least five meta-analyses supporting chronic pain, ACT is a crowd favorite. For many professionals, it is the treatment of choice when one is caught in a struggle with pain control and avoiding life. In many ways, ACT challenges conventional notions of pain management that focus on pain reduction and other “feel good” approaches. 

#3: Pain Neuroscience Education (PNE)

Know pain, know gain! When it comes to pain, a fundamental part of coping is how much a person knows about pain.

Pioneered by physical therapists, and widely adopted by all licensed health professionals, pain neuroscience education (PNE) is an educational intervention that focuses on teaching people about the neurobiological and neurophysiological processes involved in the pain experience. Through metaphor, stories, and analogies, PNE simplifies complex topics and teaches people about pain physiology including:

  • Central sensitization
  • Peripheral sensitization
  • Hypersensitivity
  • Inhibition
  • Neuroplasticity

A reconceptualization occurs through explaining pain, including the important distinction between acute pain (an indicator of tissue damage) versus chronic pain (a condition of the CNS and poorly related to tissue damage). This reconceptualization reduces the threat value of pain. People feel reassured and reengage with movement and activity without the fear of damaging their bodies.

The research supporting PNE is growing like wildfire with meta-analyses supporting its use to decrease pain, disability, fear-avoidance, pain catastrophization, limited movement, and health care utilization. In clinical trials, PNE is delivered in a single, two-hour session, and may require follow-up booster visits to reinforce learning. To fully optimize patient outcomes, PNE should be combined with exercise versus being used as a stand-alone intervention.  

#4: Psychologically Informed Physical Therapy (PIPT)

The more the merrier—and perhaps the more effective for the treatment of pain. Psychologically Informed Physical Therapy (PIPT) is a term used to define a more comprehensive (biopsychosocial) approach by incorporating certain cognitive-behavioral principles into the practice of physical therapy.

The theory and research supporting PIPT are sound, and its practical application aligns well with a physical therapist’s mission to help improve patient outcomes and improve the quality of life. By including cognitive-behavioral techniques like reframing thoughts, mindfulness, breathwork, relaxation training, and positive coping skills, PTs are able to address both the physical and psychological factors of pain.

Additionally, the expectation is that physical therapists should be able to recognize pain that comes from psychosocial distress and to adjust their course of treatment accordingly. Physical therapists are not diagnosing or treating psychopathology. They are trained to recognize “orange flags” alerting the clinician to serious distress or potential psychopathology which requires referral to a skilled mental health provider.

PIPT intervention techniques included the following:

  • Pacing
  • Relaxation skills
  • Graded activity
  • Graded exposure
  • Problem-solving training
  • Distraction techniques
  • Cognitive restructuring

#5: Mindfulness-Based Stress Reduction (MBSR)

What do you get when you blend science, medicine, psychology, Buddhist meditative traditions, and gentle yoga? This winning combination has helped tens of thousands of people since its inception cope with both the physical and emotional experience of pain. Mindfulness-Based Stress Reduction (MBSR) is an eight-week program that teaches people better ways to manage stress and their experience of pain.

MBSR is typically delivered in a group setting led by an instructor and includes techniques such as:

  • Mindfulness
  • Guided meditation
  • Imagery
  • Gentle yoga
  • Relaxation training
  • Breathing exercises 

Through mindfulness and meditation techniques MBSR helps people notice attitudes toward pain, with the end-goal of reframing pain as a distinctly transient event. MBSR has helped people who suffer from a variety of chronic pain syndromes, including irritable bowel syndrome, chronic low back pain, and fibromyalgia. Additionally, it also helps with overlapping conditions associated with pain, including depression, anxiety, and PTSD

Which intervention is your favorite to use in practice? Do you rely on one or infuse bits and pieces of all of them into practice? Psychologically-informed methods provide a safe, effective, and more holistic way to help people who have been stuck in the vicious cycle of pain.

References

Keefe, F. J., Main, C. J., & George, S. Z. (2018). Advancing Psychologically Informed Practice for Patients With Persistent Musculoskeletal Pain: Promise, Pitfalls, and Solutions. Physical Therapy, 98(5), 398–407. doi:10.1093/ptj/pzy024 

Richmond, H., Hall, A. M., Copsey, B., Hansen, Z., Williamson, E., Hoxey-Thomas, N., … Lamb, S. E. (2015). The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. PloS one, 10(8), e0134192. doi:10.1371/journal.pone.0134192

Godfrey E, Galea Holmes M, Wileman V, et al. Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomized controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain BMJ Open 2016;6:e011548. doi: 10.1136/bmjopen-2016-011548

Wood, L., & Hendrick, P. (2018). A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: short- and long-term outcomes of pain and disability. European Journal of Pain. doi:10.1002/ejp.1314 

Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., … Maglione, M. A. (2017). Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 51(2), 199–213. doi:10.1007/s12160-016-9844-2