Pain is one of the most common reasons for which individuals seek medical care, and a leading cause of disability across the globe. While acute pain is usually abrupt and caused by something specific, chronic pain is frequently multifactorial and more complex. Most often thought of as a physical sensation, chronic pain has the potential to impact every aspect of a patient’s life, including mood, relationships with others, professional activities, finances, and sleep. Understanding the psychological causes, impact, and treatment options associated with chronic pain is therefore crucial to restoring overall function and wellbeing.

The psychosocial component of chronic pain

The link between pain and behavioral health disorders is striking. They both share common biological and anatomical themes, and studies have shown that not only does chronic pain significantly predict the onset of depression, but depression significantly predicts the onset of chronic pain.^1,2 Further, some of the anatomical and physiological changes associated with chronic pain might be maintained not only by nociception (how pain is processed by the body), but also by psychosocial factors, and are at least partially reversible with effective treatment.³

As a result, understanding the association between chronic pain and mental health is integral to accurately identifying and successfully managing pain and pain-related comorbidities. Given that pain is both a physical and emotional experience, it should come as no surprise that the way an individual thinks and feels impacts their perception of pain.

The field of pain psychology

Pain psychologists, typically clinical psychologists with postgraduate training in pain management, aim to improve their patients’ overall function (e.g. physical, emotional, occupational, etc.). While some pain psychologists may practice independently, they frequently work as part of a broader multidisciplinary pain management team, which commonly includes physicians, nurses, physical and occupational therapists, and social workers, among others.

Although patients and healthcare providers strive for complete resolution of pain as a final outcome, this may at times be unrealistic when dealing with chronic pain. Functional improvement and pain reduction, on the other hand, are almost always within reach.

The demand for pain psychologists

As the risks and concerns associated with traditional pain medication (including, but not limited to, misuse, abuse, and addiction) have increased, so has the demand for pain psychologists. In fact, many healthcare providers now consider psychological treatment to be first-line therapy for certain types of pain.⁴

However, as is the case for behavioral health providers more broadly, there is a shortage of pain psychologists. When accounting for geographic variations in access and insurance coverage inconsistencies, finding a pain psychologist can be challenging, at best, for those most in need.

Probably as a direct response to the above-mentioned supply constraints, a growing number of online and self-guided cognitive behavioral therapy solutions (see description below) have been developed. Such self-help options have proved most effective for those with mild to moderate symptoms.

Therapies employed by pain psychologists

With the overarching aim of functional improvement, pain psychologists assist their patients with learning strategies to minimize pain and cope with the emotional and physical impact associated with pain. The following are a few examples of therapies typically employed by pain psychologists:

Cognitive behavioral therapy (CBT)

• Based on the idea that how people think (cognition) and what people do (behavior) affects the way they feel
• Aims to reduce thoughts and behaviors that lead to increased pain and replace them with positive alternatives
• Builds coping skills for dealing with negative emotions
• Frequently includes stress and anger management, mind-body interventions (e.g., Tai Chi, yoga, etc.), and relaxation techniques (e.g., focused breathing, biofeedback, etc.)

Mindfulness-based stress reduction (MBSR)

• Increases one’s awareness of feelings toward pain by focusing on the present and minimizing thoughts about the past or future
• Non-judgmental approach to thoughts as neither positive nor negative
• May include practices such as meditation, yoga, and breathing techniques

Hypnosis

• Attention-focusing procedure that uses relaxation and visualisation
• Involves hypnotic induction where changes in thoughts, emotion, and behavior are suggested to the patient
• Redirects attention away from the pain sensation
• Helps to manage unpleasant symptoms, maladaptive behaviors, and anxiety related to pain

Behavioral activation (BA)

• Focuses on practicing beneficial behaviors to activate pleasant emotions
• Based on the concept that pain-related fear leads to avoidance, lack of positive reinforcement and low motivation
• Introduces positively rewarding activities consistent with the patient’s desired lifestyle
• Particularly useful for individuals with social withdrawal due to chronic pain and depression

Group psychotherapy

• People share challenging experiences, and successful coping strategies, with others going through similar situations
• Uses group dynamics to benefit individual participants
• Increases confidence by providing a safe environment to articulate feelings
• May include support groups, cognitive-behavioral medicine groups, chronic disease self-management programs, and chronic pain self-management programs

Given the nature and complexity of chronic pain, the above-described, more traditional psychotherapeutic treatment options may not always achieve the desired outcome. In such cases, the following emerging practices may also be utilized by pain psychologists:

Distraction therapy using virtual and augmented reality

• Exposure to virtual environments with sound and video to aid with pain reduction
• Has been successfully employed in the pediatric burn population
• Associated with decreased activity in the cingulo-frontal cortex⁵

Graded motor imagery (GMI)

• Attempts to normalize central processing to assist with chronic pain
• Use is expanding and includes complex regional pain syndrome and phantom limb pain
• Frequently involves three steps:
  1. left/right judgement training;
  2. motor imagery; and
  3. mirror therapy⁶

Claims considerations

Chronic pain claims can be challenging for both the insured and the claims assessor. Pain is subjective and cannot be measured with a blood test or an X-ray. For the individual dealing with chronic pain, it can seem never-ending. Chronic pain, pain that usually lasts longer than three months, can result in decreased activity and increased isolation. It can lead to irritability, anxiety, depression, and difficulty seeing a way forward.

Treatment has traditionally focused on the following:

• Non-medication options such as physical and occupational therapy, acupuncture, chiropractic services, and massage therapy
• Non-opioid medications such as non-steroidal anti-inflammatories, acetaminophen, creams, gels, and patches
• Opioids
• Interventions such as injections, spinal cord stimulators, pain pumps, and surgery

Each of the above has its place in the care of patients with chronic pain, but they are frequently not enough to allow for the desired and necessary amount of functional improvement. Including psychotherapeutic treatment in the pain management toolbox can make a difference, and the claims assessor’s knowledge of these options can provide input and encouragement in a time of need.

Understanding function

Diagnosis does not equal disability. In Income Protection claims, it is the claims assessor’s role to understand the functional restrictions and limitations the insured experiences in the context of occupational duties. From there it is important to understand what treatment options have been explored and how the individual has responded.

Reaching out to the care provider to discuss treatment and response can be helpful – not to direct care, but to understand prognosis and how best to assist the insured in their return-to-work efforts. This can be accomplished by the claims assessor or a medical resource.

Medical outreach considerations

With chronic pain it is important to understand the whole person, i.e., to look at the underlying cause and treatment of the pain, as well as the biopsychosocial issues impacting the individual.

• What treatment options have been explored and what has the response been?
• What additional treatment is being considered?
• Are there community or medical resources available that may be of assistance?

Gathering this information and working with the care provider and the insured to develop a plan can shift the focus from what the individual is unable to do to what they can do and open the door to possibilities. It may be feasible to consider financial support for some of the therapies described in this article as part of a vocational rehabilitation or return-to-work plan.

Conclusion: Whole-person care

Pain is not simply a sensory physiological process. It’s a complex experience that is unique to each individual and should be viewed as such, to ensure that related and manageable psychological implications are not overlooked. While many with chronic pain recover over time, or adjust to their “new self,” a significant number deal with chronic emotional stress and impaired coping abilities.

Depression, anxiety, substance abuse, and post-traumatic stress disorder are common comorbidities in individuals with chronic pain, but psychological factors such as emotional support and resilience have the ability to positively impact patients’ experience with pain.⁷

Chronic pain can take on a life of its own, even larger at times than the underlying etiology, potentially impacting all aspects of one’s life. As part of a broad spectrum of pain management services, pain psychology offers an entry point for effectively identifying and managing the behavioral, affective, cognitive, and social components of the pain experience. For the majority of patients suffering with chronic pain, there will not be a single medication or treatment that will alleviate their symptoms. Incorporating psychology into the broader pain management care process can offer an effective supplementary treatment.

Available resources may be limited but the claims assessor and insurer can help identify these resources and provide support to the individual in exploring treatment options in their community.