Psykologisk Tidsskrift, NTNU, 18. årgang 01-2014, Oslo

A psychological approach to chronic pain.


Pain is internationally defined as a sensory and emotional experience. It follows that knowledge of psychology is important in understanding the phenomena of pain, and psychological approaches play a key role in treatment of chronic pain conditions. Chronic pain is quite common in the population, but poorly understood and difficult to treat. Long lasting pain has many negative consequences and can become self-reinforcing. The modern view is that chronic pain is best treated using a bio-psycho-social model. Psychological treatments include behavioural therapy, cognitive therapy and ACT (Acceptance and Commitment therapy) and seek to strengthen adaptation and coping skills.


Søren Frølich
cand. psych., Health Psychology Specialist
Retired after 30+ years of work at Multidisciplinary Pain Centers.

Our sense of pain acts as a natural alarm system and motivator for avoiding damage to our bodies. Feeling pain is useful or even necessary for survival. On the other hand pain is the cause of a huge volume of seemingly unnecessary suffering. This is especially true of persistent or chronic pain. Acute pain tends to immediately result in actions or behavior suited to minimize damage to the body and bringing the pain to an end. If these efforts prove fruitless and the pain persists for a longer period of time, the pain appears to become biologically meaningless by decreasing, instead of increasing, the individual's capacity to take relevant action. Medical interest in pain research and pain treatment grew markedly in the 1960's and 70's. The first specialized pain clinics were established, and in 1973 the International Association for the Study of Pain (IASP) was founded.

Definition of pain

IASP needed a definition that did not confound pain with its stimulus or with neuro-physiological measures, which could be subject to changes due to technological progress. The resulting and still valid definition is purely psychological or even phenomenological: Pain is… "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." (IASP, 2011) Adhering to this definition, it will likely remain impossible to measure pain in any objective sense. Neither can pain be shared with another person. When we speak of "sharing experiences" in daily life we are actually speaking of sharing a situation with certain stimuli, at the same time ignoring that the resulting experiences may vary greatly from person to person. Psychology is not just a behavioral science but also addresses the question of conscious experience and it's relationships with physical stimuli. Therefore psychology holds a central position in understanding pain as well as in the practical treatment of chronic pain conditions, where pain medications often have only limited effects.

Chronic pain

Chronic pain is most often understood as persistent or recurrent pain present for more than 6 months. In connection with treatment it is common practice to distinguish between persistent pain due to cancer and chronic "non-malignant" (non-cancer) pain. Conditions related to cancer most often show a changing combination of acute and chronic pains, following progression or regression in the basic disease. Non-cancer pain conditions on the other hand can involve symptoms persisting for many years or even a lifetime. In many cases of chronic pain no ongoing tissue damage or nociception (stimulation of pain receptors) can be found, whereas this will always be present in connection with acute pain. Chronic pain can have many different causes and affects a surprisingly large proportion of the population (15-20% in two European studies (Verhaak, Kerssens, Dekker, Sorbi, & Bensing, 1998; Sjøgren, Ekholm, Peuckmann, & Grønbæk, 2009). Chronic pain is positively correlated with female gender and increased age. Typical examples of conditions with chronic pain include: chronic headache, low back pain, neurogenic pain due to nerve damage, WAD (whip-lash associated disorder), fibromyalgia. The causes of chronic pain are complex and still poorly understood and in many cases no underlying physical pathology can be detected. In a significant number of other chronic conditions persistent pain has developed after trauma and subsequent acute pain. The understandable acute pain can be seen as triggering later chronic pain. But this still leaves the question of why this particular individual now has a chronic pain, when the majority of patients with similar traumas after a period of time become free of pain. The general view is that chronic pain is best understood and treated using a bio-psycho-social model (Turk, & Okifuji, 2002). Research in the neurophysiology of pain has produced evidence of a central sensitization process causing hypersensitivity to pain-related stimuli (Diatchenko, Nackley, Slade, Fillingim, & Maixner, 2006). Psychological vulnerabilities and ongoing "stress" are likely to influence these processes and to increase the risk of an acute pain becoming chronic (Turk, 2002). Patients with chronic pain show increased co-morbidity in relation to psychiatric diagnoses (especially depression and anxiety), but the question of cause and effect is generally unresolved. Discussions about whether a specific case of chronic pain has physical and "real" causes, or whether the causes are psychological and the pain is "all in the mind", reflect an outdated dualistic view of the mind-body relationship, and is in contrast to the bio-psycho-social model.

Psychological factors

Many psychological factors have a direct influence on the experience of pain. Pain is usually intensified by coexisting anxiety, feelings of helplessness, negative expectations and by depression. These factors can in turn be caused by the pain itself, giving rise to vicious circles. Typical pain behaviors associated with chronic pain are reduced levels of activity and fewer social contacts, resulting in less distractions and more room for thoughts about illness and pain. Stress reactions and persistent stressors are not only probable contributors to the risk of developing chronic pain, but also have a perpetuating and aggravating role, once pain has become chronic. Preventive measures to reduce these psychological risk factors should be important for pain prophylaxis, but also play a central role in psychological treatment of chronic pain conditions. A psychological evaluation of a pain patient should focus not so much on finding historical causations, but more on describing dominant pain-aggravating factors in the individual case, as possible targets for subsequent therapy.

Psychological rehabilitation

Since chronic pain in most cases cannot be cured, treatment becomes a question of successful adaptation to symptoms and coping with secondary, derivative problems. Among these are: physical disability, work insufficiency, fatigue, insomnia, reduced sexual desire and mood instability with bouts of anger or depression. Around half of the patients will develop a clinical depression after 3-5 years with chronic pain (Gallagher, & Verma, 1999). The presence of depression increases pain and decreases self-sufficiency. In these cases it is important to treat the depression first of all before more targeted pain therapy can be applied. Long lasting pain affects the basic mind-body relationship. The physical body is no longer an unconditional ally, but at times an enemy, hurting you and preventing you from doing what you are used to doing. Another, little known, consequence of chronic pain is a marked disturbance of short-term memory. Many patients tend to blame their medications or to fear for early dementia. The subject is not well researched, but existing studies confirm that ongoing pain itself can have this effect (Berryman, Stanton, Bowering, Tabor, McFarlane, & Moseley, 2013). General psychological counseling can be helpful in tackling many of these associated problems, but which therapies are best for attacking the problem of pain itself?

Coping strategies

Psychological treatment of chronic pain often works best within a multidisciplinary setting (e.g. in a pain clinic or center). Questions about medical treatments, physical exercise or economic worries can here be referred to medical specialists, physiotherapists or social workers respectively, and feedback can be obtained immediately, leaving more time to address the core issues in the psychologist's consultation. Organization in a clinic or center also facilitates establishment of group sessions for patient education. Teachers in these "pain schools" can represent a number of health professions conveying different aspects of coping strategies targeting pain experience and secondary effects. In addition to this the group setting allows the patients to share experiences and maybe most importantly to feel less alone with their fate. Many important lessons must be learned in order to live more tolerably with pain. Among these are choosing suitable, distracting activities, at the same time seeking to avoid subsequent punishment in the form of extra pains by "pacing" of the physical efforts involved. Making a personal emergency plan for handling "flare-ups", is a great help for many patients. Keeping a "pain-dairy" is often a good idea, and this can help to identify aggravating stress-factors in daily life. Open and direct communications with family and friends can help a pain patient receive necessary aid without the burden of constantly explaining oneself. A key issue is avoidance of unnecessary stress that always tends to cause additional pain. Relaxation techniques can be of great value for pain patients, often not only giving immediate relief but also diminishing long-term stress and improving quality of nighttime sleep. There are many techniques to choose from: yoga related, autogenic training, progressive relaxation, guided fantasies, transcendental or mindfulness meditations. Patients are recommended to find the method that suits them best as an individual and then practice on good days until they can also apply the technique at times when their pain is more prominent.

Psychotherapeutic approaches

Operant conditioning or strict behavioral therapy represents the earliest well-documented treatment for chronic pain. The goal was to de-condition "illness behavior" and replace it with healthy behavior. It can be argued that this approach ignores pain as an experience, but successes were achieved, especially through increases in patient's levels of activity.

Cognitive therapy

Cognitive or cognitive-behavioral therapies are to date by far the best validated psychotherapeutic techniques in treatment of pain conditions (Turk, & Okifuji, 2002). Focus is here on gaining understanding and control of the interrelations between thoughts, emotions, behavior and bodily reactions. Emotions and bodily symptoms are not usually viewed as being directly under conscious control, but they are to a certain degree indirectly influenced by beliefs, thoughts and behavior. Promoting positive thoughts and emotions can by itself over time provide alleviation of symptoms, the well known Rosenthal or Pygmalion effect of self-fulfilling expectations. Even more important are tactics of addressing and countering negative thoughts that tend to become automatic and self-perpetuating as typically seen in depression or anxiety as well as in chronic pain states.

Acceptance and commitment therapy (ACT)

ACT is described as one of the "third wave" of behavioral oriented psychotherapies and has only relatively recently proven its value in pain treatments (Wetherell et. al., 2011). ACT applies similar techniques as cognitive therapy, but is less instrumental and more focused on existential aspects, such as the personal losses, reduced quality of life and need to find new goals to pursue. Focus is on using less energy to avoid pain and instead promoting some degree of desensitization by exposure under controlled conditions. Techniques include "reframing" and "defusing", that effectively work by reality-testing cognitions and isolating them from emotional responses. This can empower the patient to gain more control with cognitive functioning and subsequent physiological reactions. ACT is often coupled with mindfulness mediation, which also provides training in acceptance and finding value in the existing possibilities. Exercises in mindfulness meditation help connect an otherwise merely mental acceptance with bodily sensations, including pain. We saw that pain was defined as a sensory and emotional experience. A mindful, observing attitude to experienced sensations helps to disengage these from emotions, relieving the emotional distress in pain experiences and thus making pain less "painfull".


Berryman C., Stanton, T. R., Bowering, K. J., Tabor, A., McFarlane, A., & Moseley, G. L. (2013).
Evidence for working memory deficits in chronic pain: a systematic review and meta-analysis.
Pain, 154, 1181-96.

Diatchenko, L., Nackley, A.G., Slade, G.D., Fillingim, R. B. & Maixner, W. (2006).
Idiopathic pain disorders - Pathways of vulnerability.
Pain, 123, 226-230.

Gallagher, R. M., & Verma, S. (1999).
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Sem Clin Neuropsychiatry, 4, 203-20.

International Association for the Study of Pain (2011). IASP Taxonomy.

National Institutes of Health (1995). Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia.
NIH Technol. Assess Statement 1995 Oct 16-18; 1-34.

Sjøgren, P., Ekholm, O., Peuckmann, V., & Grønbæk, M. (2009). Epidemiology of chronic pain in Denmark: An update.
European Journal of Pain, 13: 287-292.

Turk, D. C. (2002).
A diathesis-stress model of chronic pain and disability following traumatic injury.
Pain Res Manag. 7, 9-19.

Turk, D. C., & Okifuji, A. (2002).
Psychological Factors in Chronic Pain: Evolution and Revolution.
Journal of Consulting and Clinical Psychology, 70, 678-690.

Verhaak, P. F. Kerssens, J. J., Dekker, J., Sorbi, M. J., & Bensing, J. M. (1998).
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Wetherell, J. L. et. al. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain.
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Further reading:

Dahl, J. C., & Lundgren, T. L. (2006).
Living beyond your pain: Using Acceptance and Commitment Therapy to ease chronic pain.
Oakland, CA: New Harbinger.