It’s not uncommon for people living with chronic pain to be reluctant about seeking 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. This blog explores what we know about pain and how therapy can help.
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 can focus on their child’s safety over their own or when someone injured in the wild must keep going in order to reach for 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 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 psycho-social factors that can play a role in the development and maintenance of persistent pain, which is where therapy can be beneficial.
What might therapy for pain look like?
Everyone’s experience in therapy will be unique, but to broadly understand how therapy can be helpful for pain, I like to break it down into three different aspects of care.
1) Addressing causes
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 developed in the first place—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.
2) Targeting pain reduction
The psycho-social factors named above can all contribute to pain persisting, and addressing them can bring about positive change. In addition, interventions that calm the nervous system and cultivate a sense of safety can be central to addressing pain. This work can include many practices to calm and regulate the system, such as mindfulness (including mindful movement), somatic tracking, and breath work.
It can also be about exploring the way you relate to your thoughts. When you think a thought, do you get hooked by it? (Meaning you believe it and let it pull you around.) A familiar story for people with chronic pain is that the only person who can change their pain is a doctor or a physical therapist who focuses on identifying structural issues. Getting “unhooked” from this story, where you recognize how you can influence your pain and work with a broader range of practitioners, can lead to meaningful change.
3) Processing the emotional impact of pain
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.
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.