How to Manage the Psychological Side of Back Pain

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If you suffer from chronic back pain, you know what a miserable experience it can be. Unrelenting pain is exhausting and affects not just the body but the mind and spirit.

While back pain obviously occurs in the body, our minds and emotions can play a significant part in how we experience the pain. Neurosurgeon and spine specialist Dr. Jack Stern described the psychology of back pain in my recent discussion with him on the Think Act Be podcast. He emphasized the distinction between the raw sensation of pain and our perception of pain.

Sensation Vs. Perception

“A sensation occurs in your body—I pinch you and you sense it,” Stern explained. But the perception of pain is more complicated than the simple sensory experience of a pinch or other stimulus. “A perception happens in your brain,” Stern continued, and incorporates a wide range of experiences: emotional responses, memories, anxiety about future pain, and the meaning we give the stimulus, to name a few. For example, we might perceive the pain of the same physical pinch very differently if it’s intended playfully or cruelly.

Fear of Future Pain

Fear of future pain can have an especially powerful effect on our perception of current pain, according to psychiatrist Dr. Stuart Eisendrath. “If you tell yourself the story that this is going to go on forever,” he said, “or last indefinitely, or get more painful over time, you’re really painting a negative story about what you’re going to experience.” That story can amplify our perception of pain, as we feel not only the current pain but the enormity of all our future pain.

Pain, Stress, and Trauma

Stress can also play an important role in our pain. “Stress is universal, but each of us exhibits our stress in different locations of the body,” said Stern. “You exhibit the emotional stress physically as pain.”

If your back pain tends to get worse around busy times like the winter holidays, stress is likely an important factor. The worst back pain I’ve ever experienced happened during an especially stressful period of my life when I was dealing with a chronic illness, family conflict, and executor duties for a relative who had died.

Stern also noted that past trauma can significantly affect our experience of pain. For example, the specific location of “chronic pain may be a manifestation of a past abuse,” he said. “That’s where cognitive behavioral therapy [CBT] or other psychological treatment modalities are effective in recognizing ‘what’s going on’ and maybe dealing with the original trauma,” said Stern, “and dealing with the pain they have as a result of that trauma.”

Mindfulness and Cognitive Behavioral Therapy (CBT) for Back Pain

While pain manifests physically, it’s not just a physical experience. Thoughts and emotions can perpetuate pain, intensify it, or diminish it. “Cognitive behavioral therapy in particular has been quite effective in helping to manage back pain,” said Stern, given its explicit focus on the thoughts and behaviors that contribute to pain. The Society of Clinical Psychology, a division of the American Psychological Association, has named CBT an evidence-based treatment for chronic low-back pain.

Mindful awareness can also be an effective way to lessen the impact of back pain, especially in dealing with the fear of future pain. “When you’re worried about ‘Will I be able to stand it?’ or ‘Will this go on forever?’ you’re talking about the future,” said Eisendrath. By coming into the present, you can let go of anxious anticipation of the future. “You don’t have to worry about the future,” he said. “Can you stand it this moment?”

“If you look at what’s going on right now, you are standing it,” continued Eisendrath. “And that’s really all you have to do.” That realization can dramatically change your relationship with pain since there’s no good reason to expect that you won’t be able to tolerate pain if you’re tolerating it now. “If you can let go of that story and just focus on the painful sensations that are going on and what’s happening right now,” said Eisendrath, “it frees you from that story and reduces the resistance.”

Less resistance means less suffering. “You’re still around, you’re still conscious, and you’re focused on that present moment,” said Eisendrath. And pain diminishes “because you’re not laying on that negative story about the future. You’re just focusing on the present moment.”

Is Back Pain All in Your Head?

So pain really is “in your head”—or more precisely, in your brain. That doesn’t mean you’re imagining it; back pain is quite real, regardless of its source. It’s even possible to perceive pain in a limb that’s been amputated, as in Phantom Limb Syndrome. While a missing limb can’t send pain signals, the experience of pain is real and can be excruciating.

Stern cited research showing that parts of the brain shrink among patients with chronic pain and regenerate when the pain is resolved. “Your brain actually changes physically based on a perception,” he said. As he wrote in his excellent book Ending Back Pain, “The key is to remember that even if your pain is caused by your mind, it doesn’t mean it’s not real and not painful. It just means that you have to change something in your mind—not only in your back.”

Where to Start?

The following simple techniques are among those that Stern recommends for managing stress and tending to the psychological dimensions of chronic back pain:

• Stay connected to friends. Loving relationships are inherently mood-boosting and stress-reducing. Be careful not to isolate yourself even if your normal physical activities aren’t available to you. Find ways to be with people whose company you enjoy.
• Seek out touch. Caring contact with another human being activates the parasympathetic nervous system, which turns off the fight-or-flight stress response. Massage may be helpful, or even just a warm embrace.
• Breathe with ease. Sit comfortably in a quiet location. Close your eyes and breathe in gently for a count of three, and exhale for a count of six. As you breathe in, feel the strength in your abdomen that draws air into your lungs. Become aware of how the breath powers your connection to life and radiates through your body all the way to your hands and feet. Continue this practice for three to five minutes. (Adapted from my book, The CBT Deck.)
• Avoid fortune-telling. Anxiety about pain often triggers terrifying thoughts and images about future pain, and it can feel like these fears are certain to come true. When you notice you’re predicting some disaster, call it what it is: “That’s a fantasy.” Take a slow breath in and out, smile, and return to reality. (Adapted from my book, The CBT Deck for Anxiety, Rumination, & Worry.)
• Beware of catastrophizing. Looks for times when you’re worried that your pain is going to get worse and worse and completely ruin your life. Notice the story your mind is creating. Is there any alternative to how it might turn out—for example, that the pain will wax and wane over time? Is there any reason to suspect it might not be as bad as you fear? (Adapted from The CBT Deck.)

The full conversation with Dr. Jack Stern is available here: "How to Find Effective Treatment for Back Pain."