Chronic pain is defined as any significant pain that has persisted for longer than three months. Chronic pain can have a far-reaching impact on someone’s life, including potential reliance on pain medication, limiting one’s ability to engage in occupational and social activities, and emotional distress. There are clear links between chronic pain and depression, anxiety, and other mental health issues. Therapy has proven helpful for those experiencing chronic pain to manage their pain successfully and live full lives in spite of it.
What Causes Chronic Pain?
Causes for chronic pain may include a physical injury, like a pulled muscle, strained back, or whiplash. Diseases, like cancer, multiple sclerosis, or fibromyalgia can cause chronic pain as well. It can also be caused by underlying health conditions, such as endometriosis, inflammatory bowel disease, or Neuropathic conditions that involve nerve damage in key systems that transmit pain information.
Chronic Pain Symptoms
The symptoms of chronic pain vary from person to person and can occur in various parts of the body. Typical chronic pain symptoms include, but are not limited to:
- Lower back pain
- Knee pain
- Stomach pain
- Nerve pain
- Migraine headaches
In addition to the wide variability of the type, duration and intensity of pain, people also differ in terms of the levels of pain interference they experience in their lives and if it leads to permanent disability.
Chronic Pain & Mental Health
Naturally, chronic pain can take a significant toll on your mental health and quality of life. The emotional difficulties associated with chronic pain include the distress from the actual pain sensation, as well as secondary emotional distress caused by the impact of chronic pain. This might involve frustration related to frequent medical contact, isolation resulting from limited engagement in social or recreational activities, worries about what might come next, or hopelessness related to your condition. This combination of feelings cause a person to feel overwhelmed and experience burnout. As a result, individuals who experience chronic pain are also more likely to experience other mental health symptoms and conditions, especially depression and anxiety.1,2,3
Depression and Chronic Pain
The relationship between depression and chronic pain may actually be bidirectional, as depression has also been identified as a risk factor in the transition from acute to chronic pain.4 This can be similar to chronic illness, such as for those living with multiple sclerosis, arthritis, or heart disease. Some interesting recent research has found that the absence of cheerfulness and laughter that occurs with depression had the strongest association with pain interference ratings.3 Individuals experiencing chronic pain are also more likely to experience insomnia and fatigue, engage in problematic medication use, and report lower overall quality of life.
Some of the primary psychological mechanisms that seem to lead to worse mental health outcomes, in the context of chronic pain, include:
- Pain Catastrophizing: focusing on and thus magnifying the negative effects of pain and feeling helpless to cope with it.
- Fear of Pain: Fears surrounding the pain or the condition worsening and typically leads to more activity avoidance.
Chronic Pain and Suicide
The most pressing concern in regards to chronic pain and mental health is the fact that individuals who experience chronic pain are at increased risk for suicide. Specifically, research has found that individuals with chronic pain are at least twice as likely to report suicide behaviors or complete suicide.5
The psychosocial factors that seem to contribute to increased suicide risk for people living with chronic pain include:
- Mental defeat
- Pain catastrophizing
- Hopelessness
- Perception of being a burden
- Feeling that you don’t belong
Of note, the above psychosocial factors were more strongly related to suicide risk than actual pain characteristic (type, duration, and intensity) or physical status (pain interference or disability) was.
How Psychotherapy Fits Into Chronic Pain Management
There are many ways therapy can help you to cope with chronic pain. As we talked about, the ways you think about and manage your pain can impact whether or not you will also experience associated depression and anxiety. For instance, focusing on and magnifying the negative aspects of your pain (termed “pain catastrophizing”) typically makes you feel worse.
A therapist can help you learn to catch these thoughts patterns, so you can replace them with more balanced and helpful thoughts. Acknowledging the pain without judgment, reducing maladaptive ways of avoiding the pain (such as overusing pain medication), and learning to live a full life despite the pain.
Therapy can also teach you things about pain that will help you learn to manage it more effectively. For instance, you might learn about how pain information gets to your brain, so you can learn how to use things like distraction to reduce pain. You will also learn tools for coping with pain, such as relaxation techniques and activity pacing.
Many people with chronic already struggle with feeling like a “burden” to their friends and family, so therapy can provide you with a space where it is okay to talk about difficult emotions. A therapist can also help you learn how to get the most from your existing support system or may encourage you to begin to develop one.
Finally, working with a therapist can help you clarify and work towards what is important to you in life, so your values can define how you live, instead of your pain. The wide-scale adoption of online or video therapy has made accessing quality psychotherapy much easier, especially for those living with chronic pain or other chronic conditions.
Therapy for Chronic Pain
There are many styles of therapy available to those suffering from chronic pain including Cognitive Behavioral Therapy, Mindfulness-based stress reduction (MBSR), Acceptance and Commitment Therapy (ACT) and psychoeducational interventions.
Cognitive Behavioral Therapy (CBT) for Chronic Pain
Cognitive Behavioral Therapy (CBT) is often considered the gold standard for pain treatment because a significant body of research has demonstrated its effectiveness for a wide range of pain populations.6 CBT targets the unhelpful thoughts and behaviors that people have in response to their pain in order to improve their overall mental health and ideally, also lower their levels of pain sensation or at least interference.
CBT often begins with an exploration of how your thoughts, behaviors, and emotions are impacting you. In other words, along with your therapist, you become a sort of co-detective about your life and pain. By examining your thoughts about pain, you can identify any patterns that aren’t helpful for you in order to shift towards more helpful ways of thinking. This often includes identifying and modifying instances of pain catastrophizing.
Your CBT therapist will also help you figure out how to continue to do the things you enjoy, despite your pain. Because depression risk dramatically increases when you stop engaging in recreational, social, and work activities. You will also learn other behavioral tools for managing your pain, including activity pacing (during which you learn the optimal window to take breaks in order to reduce pain flare ups), and relaxation techniques. A typical course of CBT therapy for chronic pain is about 10-20 sessions, with follow-up as needed.
Mindfulness-Based Stress Reduction (MBSR) For Chronic Pain
Mindfulness-based stress reduction (MBSR) and other mindfulness therapy techniques have also been used to treat chronic pain.7,8 Mindfulness techniques all involve developing a present awareness of thought and sensation, without judgment or attachment.
Eventually, this practice can help you separate the pain sensation from your emotional and cognitive responses to it. Specifically, MBSR is thought to desensitize individuals to pain and to increase their comfort with difficult emotions thereby reducing maladaptive responses to pain, such as overusing prescription medication or avoiding activities.
Acceptance and Commitment Therapy (ACT) For Chronic Pain
Acceptance and Commitment Therapy (ACT) is a newer therapeutic modality that is also showing promise for managing chronic pain and improving quality of life.9 Rather than focusing on changing the way you think about pain, an ACT therapist would help you shift your behavior to be consistent with your goals and values.
Similarly, instead of focusing on reducing pain, ACT works to increase your acceptance of pain sensations, which has been shown to be predict better pain treatment outcomes, reduce depression, and decrease prescription opioid use.9,10
Psychoeducational Interventions For Chronic Pain
There are also effective psychoeducational interventions for chronic pain that typically occur in multidisciplinary medical settings.11 The delivery formats for these interventions vary, but common methods include informational support groups, individual sessions, online tutorials or phone sessions.
These interventions typically include education regarding various pain management techniques, and some include components of cognitive behavioral therapy, such as learning about pain catastrophizing. Psychoeducational groups are typically low commitment and show benefit after even a couple sessions.
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Where to Find a Therapist Who Is Familiar With Chronic Pain
If you are already working with a medical professional for your chronic pain (or for the condition your pain is secondary to), you can start by asking them about resources for your pain-related mental health. Many primary care settings or pain clinics offer pain support groups or psychoeducation groups.
Even if your doctor or medical center does not offer pain-related mental health support onsite, they can likely refer you to a therapist that specializes in pain management. It can be very helpful to have interdisciplinary teams work collaboratively on treating chronic pain. Therefore, you may want to consider signing a release of information to allow communication between the various professionals you are working with.
If you are searching for a therapist on your own, using “chronic pain” as a search term on a therapist directory site will help you find a therapist with this subspeciality. You can also search for chronic pain support and therapy groups on the same site. Alternately, because CBT and ACT are therapeutic modalities that have both been shown to be effective in treating chronic pain, you may decide to search for a therapist with this specific orientation.
In addition to general therapist search engines, the Association for Behavioral and Cognitive Therapies provides a searchable CBT therapist database. The Association for Contextual Behavioral Science provides a searchable database for ACT therapists.
Cost & Insurance
Out of pocket traditional therapy typically costs $100-200 per session. Depending on your insurance, you may be able to receive therapy at free or low cost with an in-network provider or receive partial reimbursement for out-of-network care. Unfortunately, if your insurance carrier requires a diagnosable mental health condition for treatment coverage, your therapy may only be covered if you develop secondary anxiety or depression (or other mental health condition). Group therapy options are typically cheaper, ranging from about $15-50 per session, and support and education groups are often free.
Is Therapy Effective for Treating Chronic Pain?
Cognitive Behavioral Therapy (CBT) has demonstrated small-to-medium effect sizes on pain-associated anxiety and depression and has even shown effects on pain and functioning that are comparable to medical care.8,12 CBT-related changes in helplessness and catastrophizing seem to be a particularly important component to long lasting change in overall functioning. The benefits of CBT have been demonstrated in a range of pain populations, including cancer, lower back pain, multiple sclerosis, and nonspecific musculoskeletal pain.
Mindfulness-based Stress Reduction has shown long lasting reductions in the severity of pain intensity and has shown small-to-medium effects on pain-related anxiety and depression.7,8 It has also been studied with diverse pain samples, including cancer-related pain, fibromyalgia, and chronic migraine. Finally, MBSR has been found to enhance treatment outcomes when combined in interdisciplinary treatment.
Acceptance and Commitment Therapy (ACT) is a newer therapeutic modality, so it has not been studied as extensively as CBT has, but it is also showing promise in treating pain-related mental health and functioning.8,9
Some studies have found medium-to-large effect sizes in treating pain-related anxiety, disability, number of medical visits, and work status. Lower effect sizes have been found for depression and actual pain. ACT has also demonstrated effectiveness with multiple pain populations, including musculoskeletal pain and whiplash associated disorders.
Another important benefit of therapy is that it is extremely low risk, especially when compared to some other pain treatment options, such as opioid medication or surgery. Research has also demonstrated the importance of receiving psychosocial interventions as early as possible. For example, one study conducted a cost benefit analysis of 1,000 participants with low back pain and found that the participants who received early psychosocial intervention reported fewer health-care visits and missed workdays.13
Living With Chronic Pain: Coping & Managing Symptoms
Living with chronic pain will naturally impact your mental health and quality of life, but there is a lot you can do to manage your symptoms and to cope with the difficult emotions that come up. Some of the major takeaways from the research on what works in therapy for chronic pain involves not exaggerating or focusing on the negative aspects of your pain or worrying about what else could go wrong with your condition.
Instead, try to stay in the present moment, do what you can to manage your pain, but accept that some pain sensation may be inevitable. Focus your attention on what you want from life and figure out a way to take your pain along for the ride.
Here are some additional ways to cope:
- Practice Active Stress Management: The muscle tension associated with stress can make chronic pain worse. Watch your stress levels and use relaxation tools, like deep breathing, to help you relax.
- Track Your Pain: Keeping some sort of record of your pain levels can help you learn more about what helps with your pain and what doesn’t. For example, if you notice you barely slept the night before a hard pain day, it is a clue that good sleep is essential to managing your pain.
- Take Breaks and Modify: Rather than not doing what you love, try to figure out a way to modify your favorite activity and/or take regular breaks. If possible, try to take breaks before your pain flares.
For Further Reading
The following are helpful resources for anyone experiencing chronic pain:
- Managing Chronic Pain Workbook: A Cognitive-Behavioral Therapy Approach, by John Otis, Oxford Univeristy Press
- Living Beyond Your Pain: Using Acceptance & Commitment Therapy to Ease Chronic Pain, by Joanne Dahl and Tobias Lundgren, New Harbinger Publications
- The American Chronic Pain Association (The ACPA)
- International Association for the Study of Pain (IASP)
- National Fibromyalgia & Chronic Pain Association
Chronic Pain and Depression, Anxiety, and Mental Health Infographics
