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People are sometimes surprised that there are psychologists who are not mental health providers. It’s also true for people with persistent pain who might wonder why their physician referred them to a psychologist for the management of their pain. ‘I’m not depressed’, they might think. The implication is that you’d only see a psychologist if you have a mental health condition, such as depression, anxiety or insomnia. It can therefore be puzzling when referring providers continue to insist on the recommendation of seeing a psychologist for pain, even when yo don’t have mental health problems.

A little known, yet similarly surprising fact about pain management is that some of the historical founders of modern pain management were psychologists. Ron Melzack, a psychologist, along with Patrick Wall, a physician, developed the first modern theory of how pain is produced in the body, highlighting the central role of the nervous system. Five decades of subsequent research coming from their theory now informs our current day understanding of pain and how to treat it. Bill Fordyce, a psychologist, along with John Bonica, a physician, are largely credited with creating the first team-based, interdisciplinary pain clinic, which continues to this day to be the gold standard for pain management.

Psychologists have thus been integral to pain management since its inception as a field within healthcare, and yet their role in pain management remains puzzling to most people with persistent pain, and even to most in society itself.

What is a Pain Psychologist?

Pain psychologists are psychologists who assess and treat pain of all kinds, including post-surgical pain, cancer pain, and chronic pain. Pain psychologists are doctoral-level healthcare providers who have had training and experience typically in health psychology and then went on to specialize in pain management. To best understand how pain psychologists help to reduce pain, let’s first discuss what a health psychologist is, and then apply this understanding to pain psychology.

Health psychology is a type of psychology that centers on the assessment and treatment of health conditions, such as pain, diabetes, Photo by Markus Winkler courtesy of Unsplash 15heart disease, obesity, among others. One common factor that underlies all these conditions is that their effective management requires more than simply relying on medical treatments alone. To best manage them, these conditions also require patients to make healthy lifestyle changes. So, for example, people with type 2 diabetes may rely on certain medications to manage their condition, but to best manage their diabetes they also need to know something about nutrition and make healthy food choices, achieve a healthy weight, get regular exercise, and manage their stress well. All of these latter changes are what we tend to call lifestyle change or health behavior change. When done over time, health behavior changes can positively affect the biological basis of these conditions and reduce the impact that these conditions have on the patient. 

Here is where the role of the health psychologists, including the subtype of pain psychologists, come into play on the healthcare team. Predominantly, physicians have expertise in medications and procedures that can positively affect conditions such as pain, diabetes, heart disease or obesity, but tend to have less expertise in coaching and motivating patients to engage in health behavior changes that also must be pursued if these conditions are to be successfully managed. In contrast, health psychologists are doctoral level healthcare providers whose expertise lies solely in helping patients to take ownership of their health, educating them on how to best manage their health condition, motivate them to start and maintain health behavior changes, and supportively coach them along the way.

Now, pain psychologists are health psychologists who have a further specialization in the management of pain. They assess pain and its many contributing causes. They also assess how the patient is responding to pain, or, in other words, the degree to which the patient is responding to the pain effectively or not. From this assessment, pain psychologist determine a treatment plan to engage the patient in making health behavior changes, which, when done over time, positively affect the physiological basis of pain and thereby reduces pain. They also show patients how to respond more effectively to pain and in so doing patients also reduce the negative impact that pain has on their life.

The therapies that pain psychologists pursue are empirically-supported. Empirically-supported therapies are therapies that scientific research shows are effective. Pain psychology therapies have been shown to reduce pain, increase quality of life, and reduce the use of opioid medications.

How do pain psychology therapies work?

Pain psychologists have a sophisticated, scientifically-informed understanding of the nature of pain. To understand how pain psychology therapies are effective, it is necessary to understand how pain is produced in the body.

Many people naturally assume that pain requires an injury or an illness to occur. This assumption is apt to come from the many times we injured ourselves or became ill and had pain. We step on a nail, for instance, and the puncture wound usually hurts. We thus come to associate pain with injury or illness. So, whenever we have pain we look for some type of bodily injury or illness that causes the pain. To treat the pain, we subsequently try to treat the injury or illness associated with the pain.

From this way of understanding pain, it’s hard to see why you’d ever want to see a pain psychologist. What role, if any, could a psychologist ever play in treating a bodily injury or illness?

This understanding isn’t necessarily wrong, but it is incomplete. We know from five decades of scientific and clinical research (beginning with Melzack, the psychologist, and Wall, the physician, mentioned above!) that the occurrence of pain also requires a nervous system. 

The nervous system consists of nerves in the body, sometimes called peripheral nerves, and the spinal cord and brain. The peripheral nerves are connected to the spinal cord and brain. Many of the peripheral nerves in the body are sensory nerves, which means that they sense things. You can feel a smooth table top because you have sensory nerves in your finger tips, which are connected to nerves in your arm, spinal cord and brain. When you touch the table top, the sensory nerves send an electro-chemical signal up the nerves to your spinal cord and brain. Your brain processes this electro-chemical signal and produces a sensation of smoothness in your finger tips. 

The same would be true if you injure yourself by, say, hitting your thumb with a hammer. Your sensory nerves in your thumb send electro-chemical signals to your brain via your spinal cord. Your brain processes this information as threatening and produces a sensory alarm that you feel as pain in your thumb that you hit with the hammer. 

We might therefore use an analogy of a building’s fire alarm system when understanding how pain works in the body. Just as there are smoke detectors located throughout a building, we have sensory nerves throughout the body. In the case of a fire alarm system in a building, smoke detectors persistently send signals to a computer on the state of the rooms in which they are located and when the computer recognizes the signal that corresponds to smoke, it sounds an auditory alarm. Similarly, sensory nerves are persistently sending signals to the brain on the state of the body — its position, what is being touched, the temperature, etc. When the brain recognizes a signal as threatening, such as when the body is injured or ill, the brain produces a sensory alarm, which we call pain. We don’t hear pain, like we hear a fire alarm, but pain functions in the same way. In other words, we don’t have an auditory alarm, but rather a tactile alarm. Despite this difference, the alarms function similarly in that they tell us that there is something wrong in the building/body. Just as an auditory alarm is produced by a fire alarm system in response to fire, our sensory alarm, or pain, is produced by the nervous system in response to something going wrong in the body.

Now, there are two things when an alarm goes off. In the case of the fire alarm, there is the fire and there is the auditory alarm produced by the fire alarm system. Similarly, with pain, or at least as we commonly think of pain, there is an injury or illness, and there is the sensory alarm, called pain, that is produced by the nervous system.

Now here’s the important part. Fire alarm systems are set at a certain level of sensitivity. We want it to sound the alarm when there is a fire, but not when we light a candle. We could imagine a fire alarm system that is set at a sensitivity that only goes off when there is a raging fire, but not a small fire. It wouldn’t be very useful. We want it set at just the right level. It shouldn’t go off in response to a candle, but it should go off with any fire bigger than a candle. The reverse settings would be equally problematic. Imagine a fire alarm system that sounds the alarm in response to a candle, or someone smoking a cigarette. Imagine further if the fire alarm system in your building was so sensitive that it went off if someone was smoking just outside the front door or on the front sidewalk. Imagine your building’s fire alarm was set at such a sensitive level that it went off with barometric changes that occur when a weather-related cold front comes through. 

In such cases, we’d want to ensure that there is no fire, of course, but we’d also want someone to reset the fire alarm system to a normal level of sensitivity, so it would only go off when there is fire.

Here is where the role of the pain psychologist comes into play. Psychologists in general are experts in helping people change their nervous systems. Usually, as we mentioned in the beginning of this essay, we think of psychologists helping people change their nervous systems to reduce things like anxiety, depression, insomnia, trauma, and addictions. But pain psychologists, with their expert understanding of how pain is produced by the nervous system, can help people with pain change how their nervous systems are producing pain — regardless of the initial cause of the pain. 

While it might be a bit overly simplistic, we might say of the two variables involved in the production of pain — injury/illness and a nervous system — that physicians tend to target the former to reduce pain while pain psychologists target the latter to reduce pain.

There are pain psychology therapies that reduce pain by reducing the reactivity of the nervous system that produces pain, whether it is the pain that follows surgery, the pain of childbirth, the pain of cancer, or chronic pain. By reducing the sensitivity of the nervous system, you reduce pain.

What does a pain psychologist do?

All pain psychology therapies target the nervous system and reduce its sensitivity to producing pain. Some therapies target how the brain processes the signals that are sent to it by the peripheral nerves in the body. These therapies help patients take a different perspective and change how they experience pain. Some other therapies target the peripheral nerves in the body and reduce their reactivity. These therapies help patients to learn how to calm the body’s peripheral nerves to change the set point of their nervous system. By doing so, their nervous systems do not react so easily and as a result their nervous system doesn’t produce pain so readily.

The former type of therapies are more cognitive in nature, meaning that they focus on changing how the brain processes the information that is sent to it by the peripheral sensory nerves. They involve helping patients learn about their pain, understand it better, and take the sense of fear or alarm out of pain. Patients come to learn that pain is unpleasant, but that it can be increasingly tolerated. Indeed, these therapies can show people how to increasingly stay grounded in the presence of the sensation of pain, and thereby learn to distract themselves from pain in the knowledge that the sensation itself is not harmful. By repetitively practicing this skill set, patients change how their brain processes the information that is sent to it by the peripheral sensory nerves.

The latter type of therapies are more behavioral in nature, which involve reseting the sensitivity of the overall nervous system, including the peripheral nerves. Reseting the nervous system is sometimes referred to as down-regulating the nervous system. As human beings, we don’t typically have voluntary control over our nervous systems. We typically can’t, for instance, simply calm down and relax despite the common admonishment from a loved one to do so when we are upset. However, pain psychologists can coach you on ways to target your nervous system and repetitively calm it down. When done over time, it tends to reset the set point for when it produces pain. So, for example, pain psychologists can coach patient in diaphragmatic breathing practices and forms of meditation that when practiced repetitively over time down-regulates the nervous system and thereby reduces average levels of pain. Pain psychologists might also recommend engaging in a mild aerobic exercise, such as walking or walking in a warm water pool or riding a stationary bike. When done on a repetitive basis, mild aerobic exercise can also down-regulate the nervous system and thereby reduce pain. There are a number of such health behavior changes that pain psychologists can coach their patients to do in a supportive manner.

Photo by Danielle Macinnes courtesy of UnsplashIn general, the overall goal of pain psychology therapies is to reduce pain and reduce the negative impact that pain has on patients. These therapies focus on what the patient can do to achieve these goals, rather than on what the healthcare system can do to achieve these goals. In this way, pain psychology therapies involve a focus on self-management. Self-management is a catchall phrase that captures the healthy lifestyle changes that patients pursue to positively affect their health.

Some of the most important things that we can do to achieve health involves things that we do, not what our healthcare providers do. In the case of pain management, some of the most effective things that can be done to manage pain are things that the patient does by targeting the nervous system. This emphasis on self-management further helps patients with chronic pain become as independent of the healthcare system as possible, such acquiring the abilities to self-manage pain successfully without the use of opioid medications

Assessments and therapies that pain psychologists perform

Pain psychologists perform a variety of assessments and therapies. The following is a brief list of the most common types of assessments and therapies.

  • Assessments
    • Pre-surgical psychological evaluations for spine surgery, spinal cord stimulator implants, and intrathecal drug delivery devices (aka ‘pain pumps’)
    • Evaluations for participation in a chronic pain rehabilitation program (sometimes referred to as functional restoration programs)
    • Psychological evaluations related to the use of opioid medications
  • Therapies
    • Cognitive-behavioral therapy
    • Acceptance and commitment therapy
    • Mindfulness training
    • Meditation and relaxation therapies
    • Chronic pain rehabilitation programs (sometimes referred to as functional restoration programs)

Research over many decades has shown these therapies to be empirically-supported, or scientifically proven to be effective. Indeed, when it comes to chronic pain management, these therapies are some of the few empirically-supported therapies that the field of pain management has.

Conclusion

Healthcare providers commonly refer patients with pain to pain psychologists because they know that what pain psychologists do is effective and important in the overall management of pain. However, it’s equally as common for people with pain to be confused by the referral, as they often do not know what it is that pain psychologists do and why it is helpful. To resolve this lack of understanding, it’s necessary to know how pain is produced in the body. Pain requires more than an injury or illness to be produced. For pain to occur, it also requires a nervous system. Both an injury/illness and the nervous system contribute to the production of pain. While some healthcare providers target their interventions at treating the initial injury or illness to reduce pain, pain psychologists target their interventions at the nervous system to reduce pain. The assessments and therapies that pain psychologists perform aim to show patients how to change the ways their nervous systems contribute to the production of pain. These therapies are empirically-supported in that they have been shown to be effective. They can reduce pain, reduce the negative impact that pain has, and can help people with pain become independent of the healthcare system in the management of their pain (e.g., help people to successfully self-manage pain without opioids). Thus, seeing a pain psychologist can be an important and helpful recommendation in the overall management of pain.

Date of initital publication: 2-14-2021

Date of last modification: 2-14-2021

Patients can sometimes question why their physicians want them to see a psychologist for pain. The concern, of course, is that they are going to get stigmatized. They might wonder, “Doesn't my doctor not believe me?” or “Do they think it’s all in my head?” This reaction can often prevent patients with chronic pain from seeking the care of a psychologist. It is, however, unfortunate. Among all healthcare providers who specialize in the treatment of chronic pain, psychologists provide some of the most effective therapies.

Published in Health Psychologist

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