Pain can have a profound social and psychological impact on those who suffer from it, and also those who care for them. Some of the psychosocial consequences of living with chronic pain include the tendency for sufferers to become dependent on medication and over-reliant on their families and other caregivers. Those in search of a solution to long-term pain can be inappropriate in their repeated utilisation of health care services, and anxious and fearful even when tended to. Such angst lends itself to withdrawal from friends and family and poor job performance if, indeed, the person feels able to continue working at all.

Chronic pain patients are frequently stigmatised as well. In an online survey of 2511 Australian adults, 58 percent of respondents reported that other people sometimes doubted the reality of their pain. Fully one out of five survey respondents had considered suicide, so pervasive was their bitterness, frustration, and depression (Pfizer Health Report, 2011; Medtronic, 2013).

While “talk therapy” admittedly does not always have the same quick response time as, say, painkilling medication, it can be hugely effective in helping the chronic pain client to come to a place of acceptance, opening the door to the establishing of a new life: one which accommodates the changes that have occurred. Below we look at both psychotherapy and cognitive therapy, including under the latter’s umbrella a couple of techniques for working with one’s mind and attention to change the relationship with pain.

Psychotherapy: Getting at the roots of the pain

Even the most conservative of medical practitioners are coming to acknowledge the close interaction between our body and our thoughts and emotions. Yet chronic pain clients are often reluctant to explore the possibility that their pain has an emotional root. Part of the stigma we named above manifests in sufferers’ fear that they will be accused of making up the symptoms or causing them on purpose, yet that is not how true somaticising works. The pain is real, and often results from unexpressed emotions literally frozen or stuck in the body. Emotions release large amounts of chemicals into the muscles and organs, and the longer they stay there, the more pain and problems they cause; the pain is just as real as any caused by a medical condition.

Too, people tend to dislike acknowledging, even to themselves, that their pain may be psychogenic, because doing so deprives them of the hope that there will be a medical cure. Instead, if the pain is psychological in origin, they must face the challenging emotions that they avoided dealing with in the first place: the ones that caused the pain. Doing this generally provides relief in both short term and long term. Unfortunately, however, if the emotions have been held for a very long time in the body, they become primarily physical symptoms, and in this case even with catharsis, chronic pain may not go away (GoodTherapy.org, 2013).

In addition to working with emotions, you have the possibility of helping chronic pain clients via a powerful tool: their minds, focused appropriately through cognitive therapy.

Cognitive Therapy: Retraining the mind and refocusing the attention

Cognitive Therapy and its associates Cognitive Behaviour Therapy (CBT) and REBT (Rational-Emotive Behaviour Therapy) place thoughts and their attendant emotions at centre stage of a person’s potential for wellbeing. While sessions of psychotherapy are looking into clients’ past to explore how “unfinished business” with others and unexpressed emotions are driving pain from underground, the cognitive therapies help people to discover which thoughts (and consequent emotions) in the here-and-now are causing pain and impairing clients’ ability to live as fully as possible given the illness or injury they may have.

Changing the way a person thinks may not render him or her pain-free, but this sort of therapy shows people how to change their relationship to pain, reducing it and becoming less affected by it, thereby enhancing a person’s effectiveness in their various life roles. If you are using any sort of cognitive therapy with a chronic pain client, you are likely to be helping the person learn to cope with their lives and their pain by teaching them:

• To think more realistically about their pain and other life phenomena
• To relax more deeply than they did before
• To manage their activities given their pain
• To solve problems related to their pain and other life stresses (Winterowd, Beck, & Gruener, 2003).

You would be likely to start with a focus on pain management and move from there to other issues or concerns. The primary target for change is the client’s negative and unrealistic thoughts, images, and emotions about their pain, the consequences of having it, and other stresses. We turn now to coping techniques enhancing your client’s capacity for positive, realistic, compassionate self-talk and beliefs.

Working with unhelpful thoughts

Even if you have only had minimal training in the cognitive therapies, you know that people shape their lives by the beliefs, thoughts, and expectations that they hold. Thus Albert Ellis’ ABC Paradigm, emanating from REBT, can be enormously helpful to people in pain. You can explain how people, contrary to what they may believe, do not go directly from “A”, the Activating Event (the trigger: let’s say a strong sensation of pain), to “C”, the Consequence: a consequent strong emotion (let’s say, despair at being in pain). Rather, the emotion is mediated by a “B”, or Belief (possibly, a thought such as that “I shouldn’t have to deal with this. I’ll never feel better”) (Ross, 2006).

To help clients identify ABC chains that they might have been unconsciously creating which are causing them pain, you may encourage them to start identifying their “C”s: the consequent strong emotions that arise from (often) out-of-awareness “Bs”: beliefs which are unhelpful, unrealistic, and often based on rigid thinking, with some sort of “should” or “must” attached to them.

Ellis later added a “D”, which stands for Disputation (Ross, 2006). In order to correct an unhelpful ABC chain, a person looks to dispute the rigid, unrealistic belief it is based on and replace it with a more realistic, flexible, compassionate stance (in the example we are following, the thought that the pain will go on forever can be replaced by, say, the thought that “I can manage my pain by managing my thoughts; it is time to employ one of my pain control techniques”).

Distraction and attention: Closing the pain pathways

Managing cognitions by actively replacing limiting ones is a solid tool for pain clients to use, yet there are also other ways clients can manage pain through managing their minds. The following three facts, taken together, constitute a strong case for distracting oneself from pain by merely putting attention elsewhere.

Focusing on pain means more pain. The way we focus our attention has a lot to do with how much pain we experience. This is because every sensation of pain which registers on our consciousness sends a signal through our pain pathways. The more signals we send (i.e., the more thoughts focusing on our pain), the more pain receptors our nerves create to handle all the signals. The more receptors we have, the more sensitive our nerves become, leading to Central Nervous System Sensitisation. The more sensitivity we have, the more pain we experience. The more pain we experience, the more pain thoughts we have, in a vicious maintaining cycle (Chronic Pain Australia, 2013).

Attention is finite. You can help your clients to interrupt the cycle. Get them to think about it like this. Each of us has a finite amount of attention to give to our various life experiences. The more we give to one area, the less attention there is available for other areas. Putting major amounts of attention onto one’s pain, therefore, means much less attention for anything else. By inserting pleasurable experiences to our life, we increase our production of the so-called “feel good” chemicals – the neurotransmitters – such as the endorphins. With a high percentage of attention on our enjoyable experiences, we are emotionally and chemically reducing our pain (Chronic Pain Australia, 2013).

Attention is like a muscle: it can be strengthened by using it, and it can be directed to do the “heavy lifting” in whatever direction we require. Therefore, the name of the game in pain control is “attention enhancement”: growing the capacity for attention and then directing that newly enhanced capacity to those experiences that generate “feel-good” (i.e., pain inhibiting) chemicals, thus limiting or closing the pain pathways formerly experienced.

This means that we help clients control their pain when we help them to distract themselves from the pain – reducing pain signals – and add in enjoyable sensations and experiences, facilitating the production of pain-inhibiting endorphins. When we help them grow their capacity for paying attention, they are even more powerful at regulating these processes. Mindfulness exercises and techniques will help them do this.

Mindfulness: Being with what is; developing the Observer Self

Some of the most potent methods for developing the attention “muscle” reside in the practice of mindfulness, emanating from ancient Buddhist and other Eastern traditions but enjoying a meteoric rise in popularity as it comes to be applied in an increasingly wide range of contexts in the West. Mindfulness can be defined, in part, as: “Consciously bringing awareness to your here-and-now experience, with openness, interest, and receptiveness” (Harris, 2007).

Mindfulness practices include both meditative and non-meditative ways of concentrating awareness and attention. Mindfulness exercises grow out of the four primary skills: defusion (disidentification), acceptance, contact with the present moment, and spacious awareness (Harris, 2009). We offer instructions addressed to the mindfulness practitioner (say, your chronic pain client):

Exercise 1: Mindful eating. Sit down at the table with your food but no television, radio, book, computer, music, or conversation. Eat your meal paying full attention to each bite: how it looks, how it smells, and what is happening with your various muscles as you cut it and raise it to your mouth. Compare any differences you notice between food eaten this way and that eaten when you are focusing on other things. Meals eaten mindfully are more filling than others and also very good for digestion.

Exercise 2: Mindful walking. You can do mindful walking in the same way that you do mindful eating. While walking, you focus on everything in and around you: the feel of the ground under your feet; your breathing; the sky; the view; the flowers, trees, or other foliage along the route; the other walkers; the feel of the wind on your face and in your hair; the sun on your skin… If you lapse into thinking, just thank your mind for its contribution and go back to experiencing the walk. Enjoy the outing!

Exercise 3: One minute of breath. In this exercise, your task is to devote a whole minute – measured by a clock or watch in front of you – to your breath: nothing more, nothing less. What do you observe about yourself at the end of the minute? As you develop your attention muscle, you may wish to gradually extend the mindfulness time of breath focus (Exercises adapted from Elliston, 2001).

Exercise 4: Defusion practice: Developing the Observer Self. Mindfulness proponents (and Buddhists) talk a lot about developing the Observer Self and one of the core skills of mindfulness is that of defusion: that is, the capacity to disidentify from thoughts, emotions, sensations or other phenomena that one is experiencing. To create the Observer Self is to give oneself another perspective, and thus a more spacious psyche, from which to be with incoming stimuli. So if what we (or our clients) are experiencing is profound pain, there is a sense of distancing ourselves from that pain – and thus reducing it – if we are able to create a space from which we watch ourselves experiencing the pain.

You can work with clients to develop this capacity by encouraging them first to fuse (identify) with a given experience (say, intense pain), by sitting in, say, a particular chair which is named as the “Painful” Self. The person should focus intensely on the experience – let’s say it is of strong lower-back pain – for 10-20 seconds, noticing everything about that pain: what it feels like (hot, tingling, sharp, throbbing, etc.), where it is, and how “big” it is. Then instruct your client to walk across the room to another chair, this one deemed the “Observer Self”.

From this second vantage point, the client is to mentally “look back” at the Painful Self, noticing how the self looks, what it seems to be going through, what it is thinking, and so on. Ask your client if he or she experiences any distancing from the pain in the second position; is there any reduction in the sensation of pain? Having two places to put one’s awareness (at the Painful Self and the Observer Self) creates a more spacious psyche and, when done competently, a less intense pain experience.

One insight that chronic pain clients may take away from the raft of pain management techniques presented here is that they, the clients, are responsible for and – to some degree – able to control their pain. That empowering concept can be further extended to the health care professionals and specialists who work with them.

This article was adapted from the upcoming Mental Health Academy CPD course “Managing Chronic Pain”. For more information, visit www.mentalhealthacademy.com.au.

References

• Chronic Pain Australia. (2013). Helpful thinking. Chronic Pain Australia. Retrieved on 3 June, 2013, from: hyperlink.
• GoodTherapy.org. (2013). Chronic Pain. GoodTherapy.org. Retrieved on 22 May, 2013, from: hyperlink.
• Harris, R. (2007). The happiness trap: stop struggling, start living. Wollombi, NSW, Australia: Exisle Publishing, Ltd.
• Medtronic. (2013). Improving life by easing chronic pain. Medtronic, Inc. Retrieved on 22 May, 2103, from: hyperlink.
• Pfizer Health Report. (2011). Australians living with chronic pain. Pfizer Health Report, 46, p 4.
• Ross, W. (2006). What is REBT? REBT Network. Retrieved on 3 June, 2013, from: hyperlink.
• Winterowd, C. L., Beck, A.T., & Gruener, D. (2003). Cognitive therapy of chronic pain. Academy of Cognitive Therapy. Retrieved on 21 May, 2013, from: hyperlink.