Earlier this year, I wrote a piece on how therapy can help with chronic pain for Turning Point’s blog. You can read it here, but I have woven much of the original text into this updated version.

I’ve structured this post as a blend of old and new content to intentionally illustrate that my understanding of how to most effectively help people living with persistent pain in a therapy context is always evolving. For many people, an important part of therapy being an effective intervention for pain is understanding why a psychological approach makes sense and why it can make a meaningful difference. So, if you are looking to change pain, I encourage you to read through this piece.

In the first part of the original piece, I summarized the complex nature of pain, our understanding of pain as a protective alarm, and how a whole-person approach to pain requires us to look at how psychosocial factors are impacting that protective alarm.  Except for minor edits, I’ve kept this part of the original post as is.

First Part of the Original Post

It’s not uncommon for people living with chronic pain to be reluctant to seek help from a therapist. For some, it feels like admitting that their pain isn’t real and that it is “all in their head.” Others don’t see how a mental health provider could help with something they see as a physical issue.

What do we get wrong about pain?
We tend to misunderstand pain as a symptom of tissue damage. But we didn’t just make this idea up. It dates back to nineteenth-century medical textbooks, which stated either that pain had an objective visible cause or that it was imaginary and all in one’s head. Despite decades of research demonstrating otherwise, this misconception persists and influences the types of practitioners that people seek when they are navigating ongoing challenges with pain.

If pain isn’t a measure of tissue damage, what is it?
Pain is a protective alarm. It alerts us to the possible need to protect our body. Our brain constantly scans for danger—whether from an injury, inflammation, or even emotional stress—and if it interprets a potential need to take action to keep our body safe from threat, it will sound the alarm.

But it (usually) hurts when I hurt myself.
Absolutely. If I break a bone (an example of a structural problem in the body), that will result in a flood of danger signals being sent up to my brain, and in most situations, I will experience pain. The critical thing to understand is that I don’t experience pain because I have a broken bone. My brain produces pain to pull my attention to this injured part of my body so that I can take action to keep myself safe.

Sometimes, though, severe injuries don’t immediately cause pain. This can happen, for example, when a parent is hurt but focused on their child’s safety over their own, or when someone injured in the wild must keep going to access help. Can you think of a time when your body was harmed but you didn’t feel pain at first (or at all)?

What about persistent pain?
When we understand pain as an alarm, we can begin to appreciate that many different factors can contribute to its persistence. Research shows that the sensitization of the pain system plays a role in persistent pain. We now understand more about how the pain and immune systems interact, with inflammation providing a danger signal. (It makes sense that these systems are working together—both are trying to protect us!) We also understand a lot more about psychosocial factors that can play a role in the development and maintenance of persistent pain, which is a place where therapy can be beneficial.

Reflections & Edits to the Second Part

In the second part of the original post, I broke therapy for pain down into three different aspects of care. Writing this was a helpful process for me as a clinician. It has helped me to communicate more clearly with clients in session about the different types of work that could be involved in therapy for persistent pain.

But, as I have spoken about it with more and more clients, I have refined my framing of these three different aspects of care—and added a fourth. Here is how I am broadly thinking about the different ways that therapy can help with persistent pain:

1) Coping with all the things that pain makes hard.

In the original post, the heading for this section is “3) Processing the emotional impact of pain“, and what I wrote in the paragraph under this heading still captures a lot of what this part of the work can look like. Here is what I wrote originally:

Living with ongoing pain can be incredibly challenging. Many people experience profound grief for the person they once were and the life they once lived before pain. Pain can play into a vicious cycle of fear and anxiety, as fear and anxiety make the pain worse, and the fear of making the pain worse can significantly increase anxiety. Living with pain can also make us feel irritable a lot of the time. And it’s common for folks to be angry about how their life has changed, angry that things haven’t improved, and angry that no one seems to be able to help. Living with chronic pain can also result in heartbreaking levels of isolation and loneliness. And then, of course, there is depression. It’s common for folks to feel depressed—and even suicidal—when they are facing relentless pain. Understandably, these emotional challenges get pushed to the side in favour of pursuing interventions aimed at “fixing” the possible physical causes of the pain. Ironically, many people find greater relief and healing through work that addresses the emotional pain of living with physical pain. 

Something that I didn’t mention in the original post is that, historically, this has largely been considered the role of therapy in pain care. We haven’t historically looked to therapy to change pain; we have looked at therapy as a resource for helping people cope with pain. While I don’t want to downplay the meaningful role that therapy can play in helping people to face the challenge of living with persistent pain, therapy has a lot more to offer than just coping skills.

2) Learning helpful tools and strategies

This aspect of care is a new addition to this piece. I think I originally missed it because I associate these things so strongly with the work that I did as a group program facilitator at Change Pain for well over a decade. But they also come up regularly and consistently in therapy. Examples of this work can include things like working with tools from Cognitive Behavioural Therapy for Insomnia (CBT-i) to improve sleep, coaching around pacing to help avoid pain flare-ups, and guidance around graded activity to support folks in slowly increasing their activity levels. Relaxation and mindfulness practices are another example of this aspect of care, and practicing communication skills is another common piece. People often find it difficult to communicate with others about their challenges with pain, whether it is family and friends, co-workers, or other healthcare providers, and therapy can provide the opportunity to develop helpful skills in this area.

3) Addressing predisposing and maintaining factors

In the original post, I titled this aspect “1) Addressing causes.” There are many psychosocial factors known to make developing persistent pain more likely (predisposing factors), as well as many factors known to keep people in pain (maintaining factors). The original post does a nice job of succinctly summarizing some of these factors. Here is what I wrote about them:

There is a lot to unpack here. Often, people living with pain want to get back to how things were before the pain started, but it is important to remember that there are reasons the pain persisted—and many of them might have nothing to do with the physical structure. 

Trauma is an important piece. People with chronic pain are 8.5 times more likely to have PTSD, and up to 75% of those seeking PTSD treatment also live with pain. Early life trauma increases the risk of developing chronic pain later in life, and in some cases, chronic pain can be considered a legacy feature of trauma. Processing and integrating trauma can be a key part of healing. 

Other factors known to play a role in the development and maintenance of persistent pain include people pleasing, perfectionism, anxiety, catastrophic thinking, emotional suppression, hypervigilance, fear-avoidance behaviours, a hyper-focus on problem-solving, disconnection from one’s internal state, a lack of boundaries, and self-criticism. In different ways, these factors all reinforce the perception of a lack of safety and can play a role in chronic pain. 

What I want to change from the original post is the use of the word causes. Persistent pain is complex. To refer to anything as the cause of pain is an oversimplification. Pain is multifactorial, meaning that it is influenced by many different factors—including predisposing and maintaining factors that can be addressed in therapy.

4) Training your body’s system to experience more safety

This final aspect was referred to as “2) Targeting pain reduction” in the original post. What I wrote in the original piece only scratches the surface of what this work can involve, and it is worth revising.

Understanding this part of the work comes back to understanding pain. Remember, pain is a protective alarm. It is alerting you that a part of your body may need protecting. When your brain decides to sound (or not sound) this protective alarm, it is taking into account every piece of information it has about whether you are safe or under threat.

Read the sentence above again. And then really let it sink in.

Training your system to experience more safety is going to involve building resources to help you access experiences of feeling safe, as well as challenging things that your system has learned to experience as threats. Not everything we have learned we need to protect ourselves from is actually something we need to protect ourselves from—and feeling our feelings is a great example of that for many people.

There is an incredibly wide range of things that could be involved in training an individual’s system to experience more safety, but broadly, it can include things like retraining our relationship to emotions and sensations (like pain itself), learning to express parts of ourselves that were disavowed in our early life experiences, and exploring the deeper motivation behind habitual behaviours.

The Original Ending—A Hopeful Outlook

When we are stuck in the story that pain results from a structural problem in the body, there is only one path forward: we must find a practitioner to identify the problem and fix it. When we embrace a modern understanding of pain, there is much more possibility and many different paths forward. For years, pain treatment focused on management—helping people cope but assuming pain would always remain. In recent years, however, there has been a shift. Leading researchers and clinicians are talking about recovery. While I don’t believe that the human experience is ever a pain-free one (however one defines pain), I have witnessed remarkable healing, and we have more tools than ever to help people move beyond chronic pain. And therapy can offer access to some of those incredibly powerful tools.